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. Demonstrate proper securing of the restraints is the most important action because it educates the UAP and prevents potential complications such as injury, infection, or circulation impairment.
A. Ensure that the restraints are not too tight is an important action, but it is not enough to address the issue of improper securing of the restraints. The nurse should also teach the UAP how to secure the restraints correctly and safely.
B. Complete an adverse occurrence/incident report is not the most important action because it does not correct the immediate problem or prevent harm to the client.
D. Initiate the facility’s restraint flow sheet is an important action, but it is not urgent or critical in this situation. The nurse should document and monitor the use of restraints according to the facility’s policy, but only after ensuring that they are applied correctly and appropriately.
Correct Answer is D
Explanation
D. Starting with less sensitive questions allows the nurse to establish rapport with the client and create a comfortable environment before addressing more sensitive topics. This approach helps build trust and encourages the client to open up about their concerns regarding sexual activity.
A. Sharing personal values may not be appropriate as it could potentially introduce bias or make the client feel uncomfortable if their values differ from those of the nurse.
B. Asking vague or nonspecific questions may result in incomplete or unclear information from the client, leading to ineffective assessment and care planning.
C. Starting with the most difficult questions may cause the client to feel overwhelmed or defensive, hindering open communication.
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