The practical nurse (PN) should collect the following information during the admission assessment of a terminally ill client to an acute care facility:
Health care proxy documentation.
Name of funeral home to contact.
Client's wishes regarding organ donation.
Contact information for the client's next of kin.
Contact information for the client's next of kin.
The Correct Answer is A
This is the information that the PN should collect during the admission assessment of a terminally ill client to an acute care facility. Health care proxy documentation is a legal document that appoints a person to make health care decisions for the client when they are unable to do so themselves. It is important to have this information in case the client's condition deteriorates and they need end-of-life care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A heart rate of 120 beats/minute in a 2-month-old infant is within the expected normal range, so there is no immediate need to alert the charge nurse. Routine findings should be documented and managed according to standard protocol.
B. Digoxin should be withheld in infants if the apical heart rate is below 90–110 beats/minute depending on age. Since the infant’s heart rate is within the normal range, withholding the medication is not indicated.
C. Digoxin can be safely administered because a heart rate of 120 beats/minute is appropriate for a 2-month-old infant. Documenting the heart rate ensures accurate recording of the assessment prior to administration and supports safe medication practice.
D. There is no indication to delay or recheck the heart rate in 1 hour because the current rate is within normal limits. Delaying medication could interfere with therapeutic management.
Correct Answer is B
Explanation
Explanation: In this scenario, the sudden regurgitation and cyanosis in a 24-hour-old infant indicate a potential airway obstruction or compromise. The immediate priority is to clear the airway and ensure adequate ventilation.
Suctioning the oral and nasal passages helps remove any potential obstruction or mucus that may be causing the cyanosis. This intervention aims to restore normal airflow and prevent further respiratory distress in the infant.
Let's briefly evaluate the other options:
A) Turn the infant onto the right side.
Positioning the infant on the right side does not directly address the potential airway obstruction or cyanosis. While positioning may have some benefit in certain situations, such as facilitating drainage, it is not the most appropriate immediate intervention in this case.
C. Give oxygen by positive pressure.
Administering oxygen by positive pressure may be necessary if the infant's oxygen saturation remains low after suctioning and clearing the airway. However, suctioning should be the initial intervention to address any potential airway obstruction or mucus before considering oxygen administration.
D.Stimulate the infant to cry.
Stimulating the infant to cry is not the appropriate intervention in this case. It does not directly address the potential airway obstruction or cyanosis. Crying requires a patent airway, and if the infant is already cyanotic, it suggests an obstruction or inadequate ventilation. Therefore, suctioning and clearing the airway takes precedence over stimulating the infant to cry.
In summary, when a full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic, the practical nurse should immediately suction the oral and nasal passages to clear any potential airway obstruction or mucus. This intervention aims to restore normal airflow and ensure adequate ventilation for the infant.
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