The nurse is caring for a client diagnosed with cancer. The client has discussed having a DNR order written but is undecided. The nurse enters the client's room with their domestic partner sitting at the client's bedside. The nurse assesses that the client is not breathing spontaneously & unresponsive. What is the first appropriate action by the nurse?

Assist the significant other out of the room.

Activate the facility's response system for a code

Inform the physician that the client is apneic.

Ask the client's partner to make a DNR decision immediately.

Answer and Explanation

The Correct Answer is B

B. Activating a code blue or the facility's emergency response system will bring immediate assistance and resources to the client's bedside. This is crucial to initiate prompt resuscitative measures if indicated and to involve additional healthcare providers in the management of the emergency.

A. While it might be appropriate in some situations to provide privacy or support to the partner, in this urgent scenario where the client is unresponsive and not breathing, the priority should be immediate assessment and intervention for the client's condition.

C. While notifying the physician is important, especially to inform them of the client's condition and potentially discuss the DNR status, it is not the most immediate action in this urgent situation where the client is unresponsive and not breathing. Direct intervention and assessment are needed first.

D. Asking the partner to make a DNR decision immediately is not appropriate as the first action in this scenario. It is crucial to focus first on the client's immediate needs for assessment and potentially resuscitative measures if indicated. The discussion about the DNR order should occur in a timely manner but is secondary to addressing the client's current medical emergency.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. Establishing a trusting relationship is crucial in nursing care, including when addressing spiritual distress. This intervention allows the nurse to create a safe space for the client to express their feelings, concerns, and spiritual beliefs. It fosters open communication and helps the nurse understand the depth of the client's distress, which is essential for providing effective support and care.

B. Understanding the client's belief system, including their beliefs in a Supreme Being or higher power, is important in addressing spiritual distress. This information helps the nurse provide culturally and spiritually sensitive care that aligns with the client's values and preferences. However, while important, this would typically follow establishing a trusting relationship as it involves a deeper understanding of the client's spiritual perspective.

C. This response may come from a well-intentioned desire to reassure the client, but it oversimplifies the client's concerns and does not address the root of spiritual distress. Spiritual distress is often complex and may involve existential questions, fears, or conflicts related to beliefs, meaning, and purpose.

Offering simplistic reassurances without addressing these deeper issues may not effectively alleviate the client's distress.

D. Spiritual distress is distinct from physical problems, although it can manifest with physical symptoms. Focusing solely on the physical aspects may overlook the spiritual and existential concerns that underlie the client's distress. While it's important to assess physical symptoms comprehensively, this approach does not directly address the spiritual distress identified by the nurse.

A. Handling the skin gently B. Ensure daily bathing C. Clothing that will maintain body warmth D. Using skin moisturizers after bathing E. Fluid intake of no more than about 1000 mL

Correct Answer is ["A","C","D"]

Explanation

A. Older adult skin is typically more fragile and prone to injury and tears due to decreased elasticity and thinning. Handling the skin gently helps prevent trauma, skin tears, and bruising, promoting skin integrity and comfort.

C. Older adults are more susceptible to temperature changes and may have difficulty regulating body temperature. Appropriate clothing that helps maintain warmth without causing overheating is essential. This includes wearing layers that can be easily adjusted and using fabrics that are breathable and comfortable.

D. Older adult skin tends to be drier due to decreased oil production and reduced hydration levels. Applying moisturizers after bathing helps replenish lost moisture, maintain skin hydration, and prevent dryness and cracking. It is important to choose moisturizers that are suitable for older adult skin and free from irritants.

B. Daily bathing may not be necessary or suitable for all older adults. Excessive bathing can strip the skin of natural oils, leading to dryness and irritation. Instead, the nurse should promote bathing frequency based on individual skin needs, such as using mild, moisturizing cleansers and lukewarm water.

E. Adequate hydration is crucial for maintaining skin health and overall well-being in older adults. While fluid needs vary among individuals, restricting fluid intake to such a low level (1000 mL) is generally not

appropriate unless medically indicated. Older adults should be encouraged to maintain adequate hydration to support skin elasticity, circulation, and overall health.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses that a client is experiencing spiritual distress. What should be the nurse's primary intervention?

Correct Answer is A

Explanation

Because of the skin changes in the older adult client, what interventions should the nurse ensure in their care? (SELECT ALL THAT APPLY)

Correct Answer is ["A","C","D"]

Explanation

When responding to a call light, the nurse finds a client lying on the floor, with the bed linens around the legs. Which chart entry should the nurse document for this finding?

Which of the following would be a barrier to active listening?

A client who has advanced cancer has been placed on hospice care, and the nurse is helping the client to understand what that means. Which statement made by the client indicates that teaching was effective? "I will:

The nurse is prioritizing a client's problem list. Which of the following problems should receive the highest priority?

A nurse is caring for a client receiving 0.9% NSS infusing at 150 mL/hr. Which statement(s) made by the client should alert the nurse to suspect fluid overload? (SELECT ALL THAT APPLY)

The nurse reviews the list of medications that will be administered through a client's new gastrostomy tube. All medications were previously given PO. Which medication order will the nurse question?

The nurse is assessing internal variables that influence a client's health care beliefs and practices. As part of this assessment, the nurse should consider the client's:

The nurse is providing care for an elderly client who has cognitive changes. The nurse recognizes that which statement regarding dementia and delirium is true?