Nokea
A family requested a visit from a hospice nurse as they think the client appears to be nearing the end of life. The nurse assesses the client. Which of the following signs indicate that the client is near death?
- A. Decreased muscle tone, relaxed jaw muscles, sagging mouth.
- B. Urine output is clear yellow.
- C. Altered breathing (apnea, labored or irregular breathing, Cheyne-Stokes pattern).
- D. Congestion/increased pulmonary secretions; noisy respirations (death rattle).
Correct Answer: A,C,D
Rationale: Muscle tone, breathing, and secretions indicate nearing death.
You may also like to solve these questions
The nurse is teaching a client about a newly prescribed medication. To confirm that the client is learning the critical information, which strategy is most important for the nurse to include during the instruction?
- A. Provide client-focused information.
- B. Observe the client’s body language.
- C. Ask the client for learning feedback.
- D. Reinforce key points with the client.
Correct Answer: C
Rationale: Feedback confirms understanding.
The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?
- A. Inspects crutches to ensure rubber tips are intact.
- B. Practices bicep and triceps isometric exercises.
- C. Bears body weight on the palms of hands during the crutch gait.
- D. Progresses to foot touchdown and weight bearing of the affected leg.
Correct Answer: C
Rationale: Inspecting tips ensures safety.
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?
- A. Remove dentures or other oral appliance.
- B. Elevate the head of the bed to a 45-degree angle.
- C. Apply the client’s positive airway pressure device.
- D. Put and lock the side rails in place.
Correct Answer: C
Rationale: CPAP prevents airway collapse.
A 45-year-old client with breast cancer which has metastasized is receiving hospice care. The client is at home and the family is concerned about their loved one. The nurse assesses the client. Which of the following signs indicate that the client is near death?
- A. Decreased muscle tone, relaxed jaw muscles, sagging mouth.
- B. Urine output is clear yellow.
- C. Altered breathing (apnea, labored or irregular breathing, Cheyne-Stokes pattern).
- D. Congestion/increased pulmonary secretions; noisy respirations (death rattle).
Correct Answer: A,C,D
Rationale: Muscle tone, breathing, and secretions indicate nearing death.
The nurse is teaching a client about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?
- A. Wears gloves to dispose of the needle and syringe.
- B. Dons a face mask before administering the medication.
- C. Washes hands before handling the needle and syringe.
- D. Removes the needle before discarding used syringes.
Correct Answer: C
Rationale: Hand hygiene prevents infection.