Patient Data

Exhibits

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

Answer and Explanation

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.

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Correct Answer is B

Explanation

B. This response demonstrates empathy and acknowledges the client's frustration without condoning or reacting defensively to their cursing. It validates the client's feelings and opens the door for further communication about their needs and concerns.
A. This response acknowledges the client's struggle and offers a solution for future assistance with dressing. However, it may not effectively address the client's current frustration and emotional distress.
C. This response addresses inappropriate behavior but does not directly address the client's frustration or provide support for their current situation.
D. This response focuses on the technical aspect of dressing and does not address the client's emotional distress or frustration. It may come across as dismissive of the client's feelings.

A. Radial pulse volume is 3+. B. Capillary refill time is 2 seconds. C. Blood pressure is 142/88 mm Hg. D. 2+ edema of fingers and hands.

Correct Answer is D

Explanation

D. Edema of the fingers and hands can impair circulation and peripheral perfusion, which may affect the accuracy of oxygen saturation readings obtained from a pulse oximeter. Edema can interfere with the transmission of light through the tissues, leading to inaccurate readings.
A. A strong radial pulse volume indicates adequate peripheral perfusion and may not directly contribute to a lower oxygen saturation reading.
B. A capillary refill time within the normal range (typically less than 2 seconds) suggests adequate peripheral circulation and may not directly contribute to a lower oxygen saturation reading.
C. While hypertension can potentially affect oxygen saturation through its impact on systemic vascular resistance and tissue perfusion, a blood pressure of 142/88 mm Hg alone may not significantly contribute to a lower oxygen saturation reading.

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Patient Data Exhibits Drag from the Word Choices to complete the sentence. The nurse determines the client is near death as evidenced by

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which response is best for the nurse to provide?

Correct Answer is B

Explanation

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

Correct Answer is D

Explanation

A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?

The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?

An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

The nurse is assessing a client who reports a 3 day history of vomiting and diarrhea and experiencing difficulty in tolerating oral fluids. Which urine specific gravity value would the nurse expect to see on initial testing? Reference Range: Urine Specific Gravity [1.005 to 1.03]

The nurse observes the unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

A client who had emergency gallbladder surgery yesterday is getting ready for discharge. The client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?

The nurse is reviewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client's plan of care? Select all that apply.

Patient Data

Exhibits

Drag from the Word Choices to complete the sentence.

The nurse determines the client is near death as evidenced by