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Which intervention should the nurse include in the plan of care for a terminally ill client who is weak, mouth breathing, and refusing anything to eat or drink?
- A. Record the client’s daily weight.
- B. Maintain in high Fowler’s position.
- C. Keep mucous membranes moist.
- D. Report any change in urine color.
Correct Answer: C
Rationale: Moist membranes enhance comfort.
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Nurse’s Notes
The client is an 81-year-old male with a history of hypertension, heart failure, and seasonal allergies. He was admitted for pneumonia 3 days ago and is currently in the intensive care unit. The client lives with his daughter and her family, who report that he is compliant with his medication regimen. The client walks every morning but has shown cognitive decline at home and has no signs of improvement. The client has been experiencing increased confusion, lethargy, and decreased appetite. He has also developed a persistent cough with greenish sputum and shortness of breath
Medical History
• Hypertension
• Heart failure
• Seasonal allergies
• Pneumonia (admitted 3 days ago)
Diagnostic Results
• White Blood Cell (WBC) count: 15,000/mm³ (4,500-11,000/mm³)
• C-reactive protein (CRP): 12 mg/L (<3 mg/L)
• Blood urea nitrogen (BUN): 25 mg/dL (7-20 mg/dL)
• Serum creatinine: 1.5 mg/dL (0.6-1.2 mg/dL)
• Chest X-ray: Bilateral infiltrates
Vital Signs
• Temperature: 38.5°C (101.3°F)
• Heart rate: 110 beats per minute
• Respiratory rate: 28 breaths per minute
• Blood pressure: 140/90 mmHg
• Oxygen saturation: 88% on room air
Provider’s Prescriptions
• Administer IV antibiotics as prescribed
• Administer oxygen therapy to maintain SpO2 > 92%
• Monitor vital signs every 4 hours
• Encourage fluid intake
• Perform chest physiotherapy
Physical Examination Results
The client appears pale and diaphoretic. He has bilateral crackles in the lower lung fields and diminished breath sounds. The client is using accessory muscles to breathe and has a productive cough with greenish sputum. His skin is warm to the touch, and he has mild peripheral edema in the lower extremities. The client is alert but disoriented to time and place.
A nurse is caring for a client in the intensive care unit. Exhibits:Complete the diagram by specifying which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.
- A. Administer diuretics as prescribed, Increase oxygen flow rate, Perform chest physiotherapy, Administer bronchodilators as prescribed, Elevate the head of the bed
- B. Acute respiratory distress syndrome (ARDS),Congestive heart failure exacerbation,Hospital-acquired pneumonia,Chronic obstructive pulmonary disease (COPD) exacerbation
- C. Oxygen saturation, Blood pressure, Respiratory rate, White blood cell count, Serum creatinine
Correct Answer:
Rationale: Hospital-acquired pneumonia fits symptoms; chest physiotherapy clears secretions; oxygen saturation and WBC monitor progress.
The nurse is interviewing a client with lower abdominal pain and dysuria, and needs to ask the client about sexual activity. Which approach is best for the nurse to use?
- A. Begin with queries that are less sensitive in nature.
- B. Ask queries in a vague, non-specific format.
- C. Get the most difficult queries over with first.
- D. Share personal values to put the client at ease.
Correct Answer: A
Rationale: Less sensitive queries build rapport.
The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?
- A. Ensure bevel of the needle is pointing up.
- B. Massage the site gently after injection.
- C. Hold the syringe perpendicular to the skin.
- D. Select upper arm as the injection site.
Correct Answer: A
Rationale: Bevel up ensures proper delivery.
A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?
- A. Active bowel sounds in the lower right quadrant.
- B. Contraction of the left pupil when light shines in the right eye.
- C. Basilar lung sounds that are diminished in the left lung.
- D. Capillary refill of 2 seconds in the lower right foot.
Correct Answer: C
Rationale: Abnormal findings are documented.
Which intervention is most important for the nurse to implement before leaving a postoperative client with severe obstructive sleep apnea (OSA) 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.