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As a client who is terminally ill has been receiving high doses of an opioid analgesic for the past month and becomes unresponsive to verbal stimuli as death approaches, what orders would the nurse expect from the healthcare provider?
- A. Decrease the analgesic dosage by half
- B. Discontinue the analgesic
- C. Continue the same analgesic dosage
- D. Prescribe a less potent drug
Correct Answer: C
Rationale: Continuing the same dosage of analgesic is appropriate to manage pain effectively as death nears and the client becomes unresponsive. The primary goal of palliative care in end-of-life situations is to ensure comfort, regardless of the client's level of consciousness. Decreasing the analgesic dosage or discontinuing it could lead to inadequate pain relief, which goes against the principles of palliative care. Prescribing a less potent drug may also compromise pain management in this critical stage. Therefore, maintaining the same analgesic dosage is the most appropriate action to provide comfort and alleviate suffering.
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A client with asthma has low-pitched wheezes present on the final half of exhalation. One hour later the client has high-pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client
- A. Has increased airway obstruction
- B. Has improved airway obstruction
- C. Needs to be suctioned
- D. Exhibits hyperventilation
Correct Answer: A
Rationale: The correct answer is A: 'Has increased airway obstruction.' High-pitched wheezes extending throughout exhalation indicate a worsening airway obstruction, leading to increased resistance in the airways. Low-pitched wheezes present on the final half of exhalation may suggest some level of obstruction, but the change to high-pitched wheezes throughout exhalation indicates a progression in the obstruction. Choice B is incorrect as the change in wheeze characteristics signifies deterioration rather than improvement. Choice C is incorrect as suctioning is not indicated based on the wheeze assessment findings. Choice D is incorrect as hyperventilation does not typically present with wheezes and is not supported by the information provided.
A nurse is planning a nutrition class for a group of senior citizens at a community center and wants to emphasize the amount and types of fat in some foods versus others. What is the best teaching method for the nurse to use?
- A. Display posters with foods and inform seniors about fat content.
- B. Determine the foods most often eaten by this group and discuss the nutritional panel of each product.
- C. Show a movie about cooking with foods that are low in fat but delicious.
- D. Ask each senior to bring a food for others to taste, then estimate the fat content in these foods.
Correct Answer: B
Rationale: The best teaching method for the nurse in this scenario is to determine the foods most often eaten by the group and discuss the nutritional panel of each product. This approach directly educates the seniors about the fat content in the foods they commonly consume, making the information more relevant and applicable to their daily lives. Choice A, displaying posters with foods, may not engage the seniors effectively or provide detailed information about fat content. Choice C, showing a movie about cooking with low-fat foods, may not address the specific fat content of the seniors' usual food choices. Choice D, asking seniors to bring foods for tasting and estimating fat content, could be subjective and less educational compared to discussing concrete nutritional information from food labels.
The nurse is performing a physical assessment on a client with insulin-dependent diabetes mellitus. Which client complaint calls for immediate nursing action?
- A. Diaphoresis and shakiness
- B. Reduced sensation in the lower leg
- C. Intense thirst and hunger
- D. Painful hematoma on thigh
Correct Answer: A
Rationale: Diaphoresis and shakiness are classic signs of hypoglycemia in a client with insulin-dependent diabetes mellitus. Hypoglycemia is a medical emergency that requires immediate intervention to prevent further complications. The nurse should address this complaint promptly by providing a fast-acting source of glucose to raise the client's blood sugar levels. Reduced sensation in the lower leg may indicate peripheral neuropathy, which is a common complication of diabetes but does not require immediate action unless there are signs of injury. Intense thirst and hunger are symptoms of hyperglycemia, which also requires intervention but not as urgently as hypoglycemia. A painful hematoma on the thigh may require assessment and management, but it is not as urgent as addressing hypoglycemia.
Following-up Mrs. Luy, G5P4, you notice her eldest son is underweight and her youngest daughter looks thin and pale. Mrs. Luy's present pregnancy would mean another additional member of the family. This can be considered as:
- A. health deficit
- B. health deficit and health threat
- C. health threat
- D. foreseeable crisis
Correct Answer: C
Rationale: The correct answer is C: 'health threat.' The new pregnancy poses a health threat due to the potential strain on resources and the existing issues with the children, such as underweight and being pale. Choice A is incorrect as it does not fully capture the potential risks associated with the new pregnancy. Choice B is also incorrect as it includes 'health deficit,' which is not explicitly mentioned in the scenario. Choice D, 'foreseeable crisis,' is not the most fitting description of the situation presented.
The nurse is caring for a client on mechanical ventilation. When performing endotracheal suctioning, the nurse will avoid hypoxia by
- A. Inserting a fenestrated catheter with a whistle tip without suction
- B. Completing the suction pass in 30 seconds with a pressure of 150 mm Hg
- C. Hyperoxygenating with 100% O2 for 1 to 2 minutes before and after each suction pass
- D. Minimizing the suction pass to 60 seconds while slowly rotating the lubricated catheter
Correct Answer: C
Rationale: Hyperoxygenating the client before and after suctioning helps prevent hypoxia by ensuring adequate oxygen levels during the procedure, which briefly interrupts the client's normal breathing pattern. Choice A is incorrect because inserting a fenestrated catheter with a whistle tip without suction would not prevent hypoxia. Choice B is incorrect as completing the suction pass in 30 seconds with a pressure of 150 mm Hg may lead to hypoxia. Choice D is incorrect as minimizing the suction pass to 60 seconds may not provide enough time for effective suctioning and could lead to hypoxia.