Patient Data
Drag from the Word Choices to complete the sentence.
The nurse determines the client is near death as evidenced by
Decreased muscle tone, relaxed jaw muscles, sagging mouth
Congestion/increased pulmonary secretions; noisy respirations (death rattle)
Altered breathing (apnea, labored or irregular breathing, Cheyne- Stokes pattern)
Urine output is clear yellow
Eating soft foods
Correct Answer : A,B,C
As patient goes into cardiorespiratory failure, there is altered breathing with characteristic gasping and death rattle before complete cessation of breathing. This is followed by cessation of the peripheral nervous system with loss of tone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. A tort is a wrongful act or an infringement of a right that leads to civil legal liability. Restraint use should be based on a healthcare provider's order and should follow institutional policies and procedures. Administering restraints without proper authorization can result in legal liability, as it may constitute false imprisonment or battery.
A. In an emergency situation where a client is agitated and poses a risk to themselves or others, it may be necessary to enlist security personnel to help ensure the safety of everyone involved.
B. Administering medication behind a closed curtain is a common practice to provide privacy and confidentiality to the client.
D. Intentionally misleading a client about the nature of the medication being administered constitutes a form of deceit or fraud. However, this is not considered a tort.
Correct Answer is D
Explanation
D. The cuff is inflated higher up then released slowly. Where the sounds reappear is the systolic pressure. This allows for an accurate measurement when the pressure is released and the pulse returns.
A. Recording a pressure of 90 mm Hg when the pulse disappears would likely result in an underestimation of the actual systolic pressure.
B. Doing so immediately in this situation would not allow for the completion of the blood pressure measurement.
C. Documenting the absence of the radial pulse or releasing the valve immediately would not contribute to determining the systolic pressure
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