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Priority Decision: A terminally ill patient is unresponsive and has cold, clammy skin with mottling on the extremities. The patient’s husband and two grown children are arguing at the bedside about where the patient’s funeral should be held. What should the nurse do first?
- A. Ask the family members to leave the room if they are going to argue.
- B. Take the family members aside and explain that the patient may be able to hear them.
- C. Tell the family members that this decision is premature because the patient has not yet died.
- D. Remind the family that this should be the patient’s decision and to ask her if she regains consciousness.
Correct Answer: B
Rationale: The patient may still be able to hear even if unresponsive, so the nurse should gently remind the family of this to maintain respect for the patient's dignity and provide emotional support.
You may also like to solve these questions
What does cromolyn sodium act to do?
- A. Combat respiratory infection
- B. Constrict smooth muscle in the bronchial tree
- C. Prevent the release of histamine
- D. Terminate an asthmatic attack
Correct Answer: C
Rationale: Cromolyn sodium inhibits mast cell degranulation, preventing histamine release.
A client with acute respiratory failure (ARF) is being cared for by a nurse. The nurse should monitor the client for which of the following manifestations of this condition?
- A. Severe dyspnea
- B. Nausea
- C. Decreased level of consciousness
- D. Headache
Correct Answer: B
Rationale: The correct answer is B: Nausea. In acute respiratory failure (ARF), the body may compensate by increasing respiratory rate, leading to respiratory alkalosis. This can cause nausea due to the altered pH levels affecting the chemoreceptors in the brain. Severe dyspnea (choice A) is a common symptom of ARF but does not specifically relate to nausea. Decreased level of consciousness (choice C) may indicate severe hypoxemia but is not a direct manifestation of ARF. Headache (choice D) is more commonly associated with conditions like hypoxia, hypercapnia, or respiratory acidosis in ARF.
Which action should you delegate to the nursing assistant for the client with diabetic ketoacidosis? (Choose all that apply.)
- A. Check fingerstick glucose every hour
- B. Record intake and output every hour
- C. Check vital signs every 15 minutes
- D. Assess for indicators of fluid imbalance
Correct Answer: A
Rationale: Checking fingerstick glucose and recording intake/output are routine tasks that can be delegated to a nursing assistant. Assessing fluid imbalance and checking vital signs frequently require more skilled nursing judgment.
Denise is recovering from an open cholecystectomy. You know that because of the location of the surgery, she has an increased chance of postoperative
- A. Myocardial infarction.
- B. Respiratory complications.
Correct Answer: B
Rationale: Abdominal surgeries can increase the risk of respiratory complications due to reduced lung expansion.
Joan is apprehensive about undergoing bronchoscopy. You respond by saying
- A. The thought of this procedure seems to be disturbing you. You will be sleeping during this procedure. I will ask your physician to visit you again and answer any questions that you might have regarding the procedure.
- B. Your physician has performed this procedure frequently.
- C. I had it performed 3 years ago and I was fine.
- D. You would not feel a thing. You will be fine.
Correct Answer: A
Rationale: Option A provides emotional support, reassurance, and an opportunity for further clarification, which is essential in reducing patient anxiety.