Nokea
A 62-year-old male is dying from metastatic lung cancer, and all treatments have been discontinued. The client's breathing pattern is labored, with gurgling. The client's wife asks the nurse, 'Can't you do something to help with his breathing?' Which of the following is the nurse's best response in this situation?
- A. Direct the unlicensed personnel to assess the client's vital signs and provide oral care.
- B. Suction the client so that the client's wife knows all interventions were performed.
- C. Reposition the client, elevate the head of the bed, and provide a cool compress.
- D. Explain to the wife that it is standard practice not to suction clients when treatments have been discontinued.
Correct Answer: C
Rationale: Repositioning, elevating the head of the bed, and using a cool compress can alleviate labored breathing and gurgling (death rattle) in a dying client, providing comfort without invasive measures.
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A sedentary, obese, middle-aged client is recovering from a right iliac blood clot. The nurse should develop a discharge plan with the client that will focus on participating in which of the following activities? Select all that apply.
- A. Aerobic activity
- B. Strength training
- C. Weight control
- D. Stress management
Correct Answer: A,C,D
Rationale: Rationales: A) Aerobic activity (e.g., walking) improves circulation and reduces clot recurrence. C) Weight control decreases venous pressure and clot risk. D) Stress management reduces sympathetic activation, aiding vascular health. B) Strength training is less critical for clot management and may be contraindicated initially.
What is a priority nursing action for a client post-ileal conduit surgery?
- A. Monitor stoma color.
- B. Administer antibiotics.
- C. Encourage bed rest.
- D. Limit fluid intake.
Correct Answer: A
Rationale: Monitoring stoma color ensures viability; a pink/red stoma indicates good blood supply.
A client with diverticulosis asks about preventing flare-ups. Which recommendation should the nurse provide?
- A. Take a daily laxative to ensure regularity.
- B. Avoid nuts and seeds in the diet.
- C. Increase intake of red meat.
- D. Limit physical activity to reduce strain.
Correct Answer: B
Rationale: Avoiding nuts and seeds may reduce the risk of diverticulitis flare-ups by preventing irritation of diverticula, though evidence is mixed. Daily laxatives are not recommended, red meat is not restricted, and limiting activity is unnecessary. CN: Health promotion and maintenance; CL: Synthesize
The nurse is teaching a diabetic client using an empowerment approach. The nurse should initiate teaching by asking which of the following?
- A. How much does your family need to be involved in learning about your condition?'
- B. What is required for your family to manage your symptoms?'
- C. What activities are most important for you to be able to maintain control of your diabetes?'
- D. What do you know about your medications and condition?'
Correct Answer: D
Rationale: An empowerment approach focuses on the client's knowledge and needs. Starting with what the client already knows about their condition and medications helps tailor education effectively.
A client with peripheral vascular disease has undergone a right femoral-popliteal bypass graft. The blood pressure has decreased from 124/80 to 94/62. What should the nurse assess first?
- A. IV fluid rate
- B. Pedal pulses
- C. Nasal cannula flow rate
- D. Capillary refill
Correct Answer: B
Rationale: A significant drop in blood pressure post-femoral-popliteal bypass graft suggests possible hypoperfusion or graft occlusion. Assessing pedal pulses first is critical to ensure the graft is patent and blood flow is restored to the lower extremity. Compromised pulses could indicate graft failure, requiring immediate intervention. IV fluid rate, nasal cannula flow rate, and capillary refill are secondary considerations after confirming vascular patency.