Nokea
A nurse is caring for a client who has a terminal illness and is approaching death. Which of the following findings should the nurse identify as an indication of impending death?
- A. Hypertension.
- B. Tachycardia.
- C. Cold extremities.
- D. Diaphoresis.
Correct Answer: C
Rationale: Cold extremities are a critical sign of impending death as they indicate decreased circulation, leading to poor perfusion to the extremities. This phenomenon occurs as the body redirects blood flow to vital organs, preparing for the end of life. Hypertension and tachycardia are less likely to be seen in the terminal phase and are usually associated with other conditions like shock or sepsis. Diaphoresis, or excessive sweating, may occur in various situations but is not a specific indicator of impending death in this context.
You may also like to solve these questions
A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse?
- A. Increase in frequency of swallowing.
- B. Moderate sanguineous drainage on the drip pad.
- C. Bruising to the face.
- D. Absent gag reflex.
Correct Answer: A
Rationale: The correct answer is A: Increase in frequency of swallowing. After rhinoplasty, an increase in frequency of swallowing may indicate possible bleeding, which requires immediate action by the nurse. The client could be experiencing postoperative bleeding, and prompt intervention is necessary to prevent complications. Choice B, moderate sanguineous drainage on the drip pad, is expected in the immediate postoperative period and does not require immediate action unless it becomes excessive. Choice C, bruising to the face, is a common postoperative finding and does not require immediate action unless it is excessive or affects the airway. Choice D, absent gag reflex, would not be expected immediately following rhinoplasty and would require intervention, but the manifestation of increased swallowing frequency is a higher priority due to its association with potential bleeding.
During the admission of a client with a latex allergy, which of the following supplies has the potential to contain latex?
- A. Urinary catheters
- B. Indwelling catheters
- C. Sterile gloves
- D. Sterile gowns
Correct Answer: A
Rationale: The correct answer is A: Urinary catheters. Urinary catheters often contain latex, which can trigger an allergic reaction in clients with latex allergy. Indwelling catheters (choice B), sterile gloves (choice C), and sterile gowns (choice D) can be latex-free alternatives. However, urinary catheters are more commonly made with latex, making them a higher risk for clients with latex allergies.
When providing discharge teaching to a client with diabetes, what is the most important instruction?
- A. Check blood sugar levels once daily
- B. Administer insulin as prescribed before meals
- C. Take medication only when feeling unwell
- D. Eat carbohydrate-rich meals to stabilize blood sugar
Correct Answer: B
Rationale: Administering insulin as prescribed before meals is crucial for managing diabetes. This instruction is vital as it helps the client maintain blood sugar levels within the target range. Checking blood sugar levels once daily is important but not as critical as ensuring the timely administration of insulin. Taking medication only when feeling unwell is dangerous as it may lead to uncontrolled blood sugar levels. Eating carbohydrate-rich meals may actually destabilize blood sugar levels rather than stabilizing them, making it an incorrect choice.
What are the key signs of hyperkalemia and how should it be treated?
- A. Elevated potassium levels, muscle weakness; administer calcium gluconate
- B. Decreased potassium levels, confusion; administer potassium chloride
- C. Elevated sodium levels, bradycardia; administer sodium bicarbonate
- D. Low sodium levels, muscle cramps; administer sodium chloride
Correct Answer: A
Rationale: The correct signs of hyperkalemia include elevated potassium levels and muscle weakness. The treatment involves administering calcium gluconate to help stabilize the heart. Choice B is incorrect as hyperkalemia is characterized by elevated, not decreased, potassium levels. Choice C is incorrect as hyperkalemia does not involve elevated sodium levels, and the treatment is not sodium bicarbonate. Choice D is incorrect as hyperkalemia does not lead to low sodium levels, and sodium chloride is not the treatment for hyperkalemia.
What is the proper technique for measuring blood pressure manually?
- A. Use a stethoscope to listen for the Korotkoff sounds
- B. Ensure the patient is seated with the arm supported
- C. Use a manual sphygmomanometer
- D. Deflate the cuff slowly while listening to the heartbeat
Correct Answer: A
Rationale: The correct technique for measuring blood pressure manually involves using a stethoscope to listen for the Korotkoff sounds. Choice B, ensuring the patient is seated with the arm supported, is important but not the specific technique for measuring blood pressure. Choice C, using a manual sphygmomanometer, is a necessary tool but not the technique itself. Choice D, deflating the cuff slowly while listening to the heartbeat, is not the correct technique as the deflation should be done while listening for the Korotkoff sounds to determine the systolic and diastolic blood pressure readings.