Nursing Exam 5: Choking and Advance Directives

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Questions and Answers

Which statement indicates the client has identified methods to relieve stress?

Client will report a 50% decrease in night awakenings within 1 week.

Client can identify ways to relieve stress during the day and before bedtime. (correct)

Client maintains a sleep/wake log for 1 month.

Client establishes bedtime rituals, such as having a glass of wine before bed.

Which nursing intervention might help in promoting better sleep for the client?

Instruct the client to keep work reading material at the bedside.

Monitor bedtime food and beverage intake that might interfere with sleep. (correct)

Encourage the client to binge-watch shows before bedtime.

Advise the client to consume caffeine in the evening.

What is the best explanation of obstructive sleep apnea (OSA) that the nurse can provide?

The airway remains open, but the brain fails to send messages to the diaphragm.

It is caused by a dysfunction of mechanisms that regulate sleep and wake states.

It is a syndrome characterized by chronic difficulty falling asleep.

There is a lack of airflow through the nose and/or mouth for periods of 10 seconds or longer during sleep. (correct)

Which of the following statements is considered subjective data about the client's sleep?

The client's wife states he has been yawning a lot at home. Signup and view all the answers

What is the most appropriate room assignment for the client based on their condition?

A private room near the nursing station and report room. Signup and view all the answers

Which intervention could best promote sleep for a hospitalized client?

Avoid performing prescribed assessments every 4 hours during the night. Signup and view all the answers

Which client behavior suggests a need for further intervention regarding sleep habits?

Client consistently falls asleep during the day. Signup and view all the answers

What could be an effective intervention for a client experiencing sleep issues?

Suggest the use of a soft, conforming mattress and pillow for better alignment. Signup and view all the answers

What is the most effective nurse response to the client’s concerns about returning to work?

You seem concerned about missing work and the pressures of your job. Signup and view all the answers

Which method is best for evaluating improvement in the client’s obstructive sleep apnea (OSA)?

Obtain current vital signs, including a pulse oximetry reading. Signup and view all the answers

Which initial response is best for addressing a parent's concerns about a teenager's sleep habits?

Please tell me about your son’s sleep habits. Signup and view all the answers

Which statement provides the most accurate information about adolescent sleep patterns?

Many adolescents start developing this type of pattern as they develop independence. Signup and view all the answers

Which factor is most likely to influence the client's perception of pain?

Client's younger child is an infant who feeds every 3 hours. Signup and view all the answers

To assess the quality of the client's pain, which question is most effective?

How would you describe the pain you are experiencing? Signup and view all the answers

What behavior should the nurse document as an objective sign of acute pain?

States pain level of 5 out of 10. Signup and view all the answers

Which option best assesses the impact of pain on the client's daily life?

What activities do you find difficult because of your pain? Signup and view all the answers

What should the nurse prioritize when managing the client's pain medication?

Withhold the medication during the day to decrease napping episodes. Signup and view all the answers

In a situation where the client is showing low oxygen saturation, what should the nurse do first?

Administer oxygen via facemask immediately. Signup and view all the answers

Which task could be delegated to the unlicensed assistive personnel (UAP) regarding a postoperative client?

Administer prescribed throat lozenges as needed. Signup and view all the answers

What is the most critical action for the nurse to take before administering antibiotic medication?

Wake the client and administer the first dose of the antibiotic. Signup and view all the answers

How many 250 mg tablets of levofloxacin should the nurse administer if the order is for 750 mg?

3 tablets Signup and view all the answers

Which observation should specifically be documented in the nurse's assessment?

Excessive drainage. Signup and view all the answers

In regards to vital sign monitoring, what would be the appropriate action in this postoperative scenario?

Increase monitoring from every 8 hours to every 4 hours. Signup and view all the answers

What should be done if the client's oxygen saturation is found to be critically low?

Administer oxygen immediately. Signup and view all the answers

How many mL should the nurse expect to administer for a prescribed dose of 30 mg of ketorolac, given it comes in a concentration of 20 mg/mL?

1.5 mL Signup and view all the answers

Which site should the nurse choose for an intramuscular injection in a fairly thin client?

Ventrogluteal Signup and view all the answers

What anatomical landmark should the nurse use to locate the appropriate injection site for an IM injection?

The anterosuperior iliac spine Signup and view all the answers

When administering an intramuscular injection, which of the following actions should the nurse perform?

Use the Z-track method Signup and view all the answers

To ensure the exercise is most effective, what action should the nurse implement?

Include as many sensory images as possible in the experience Signup and view all the answers

What instruction should the nurse provide next after administering an intramuscular injection?

Apply firm pressure over the muscle Signup and view all the answers

What is the best time for the nurse to educate the client about the use of the PCA?

The day before the surgery is scheduled Signup and view all the answers

Which action should the nurse take to reduce drug errors by the nursing staff?

Submit a variance report discussing inaccuracies Signup and view all the answers

What is the total dosage of morphine the client has received in the last 4 hours?

18 mg Signup and view all the answers

What is the most likely reason for the client's change in pain management requirements?

She is receiving adequate pain control without the additional doses. Signup and view all the answers

What is the rationale for combining hydrocodone and acetaminophen in pain management?

The synergistic effect of the two medications improves pain control. Signup and view all the answers

What would be the best response by the nurse regarding the docusate sodium?

"You may need to continue the docusate sodium because most opioid analgesics, including hydrocodone/acetaminophen, cause constipation." Signup and view all the answers

What is the priority intervention for the nurse of the client?

Assess the client for signs of drug-seeking behavior. Signup and view all the answers

Which ethical principle does the nurse's response illustrate?

Confidentiality Signup and view all the answers

Why might the nurse consult the surgeon about discontinuing morphine?

To confirm that the patient's pain has lessened sufficiently. Signup and view all the answers

What potential side effect should the nurse be aware of when managing opioid medications?

Respiratory depression Signup and view all the answers

What nursing intervention should be implemented to care for the client's mouth?

Clean her mouth frequently with oral swabs. Signup and view all the answers

What intervention should the nurse implement for a patient with respiratory issues?

Suction oral secretions from mouth and throat. Signup and view all the answers

What is the best response by the nurse to a family expressing anger about their loved one’s situation?

"It must be difficult to see the changes in your mother." Signup and view all the answers

How should the nurse respond to the family's request for a massage for the client?

Inform the family massage therapists are welcome in the hospice unit. Signup and view all the answers

According to the Kubler-Ross Model, how should the nurse categorize the adolescent's statements about loss?

Denial. Signup and view all the answers

What is the best course of action for a nurse addressing a child's grief regarding a loss?

Recommend their child's questions be answered honestly in simple terms. Signup and view all the answers

Which phrase should the nurse recommend to help explain death to a child?

"She died and that makes us feel very sad." Signup and view all the answers

What information should the nurse provide to the client's spouse regarding medication orders?

This route is least likely to produce drug addiction. Signup and view all the answers

Study Notes

Study Guide Exam 5

Choking Assessment: Immediately after witnessing a client choking while eating, assess the client's ability to swallow liquids. Auscultate the lungs for adventitious breath sounds, and assess level of consciousness.
Next Course of Action: Report assessment findings to the healthcare provider. Elevate the client's head of bed to 45 degrees and instruct the spouse to maintain that position.
Advance Directives: Determine if the client has a Living Will and a durable power of attorney for healthcare (DPAHC). Explain the Patient Self-Determination Act (PSDA).
Client Comfort: Document that the client is aware of the Patient Self-Determination Act after ensuring the client and their spouse are settled; and do not require further intervention.
Spouse Concerns: Report to the charge nurse if the spouse seems to be in denial about the seriousness of the client's condition, or expresses desires for euthanasia.
Nursing Response: "How was she positioned when you fed her?" and "Saliva entering the lungs can also cause pneumonia. You did not have a way of knowing she was aspirating."
Client Mouth Care: Offer ice chips every hour, and provide mouth care daily with oral swabs.
Interventions: Encourage deep breathing, and suction oral secretions from the mouth and throat if needed.
Grief Stages: According to the Kubler-Ross Model, denial is a stage of grief.
Grief Response: The best response from the nurse is to ask patient about their experience, and allow them to express their feelings " honestly.
Medication Route Considerations: Different routes for medication administration have different benefits, including speed of absorption, and the reduced risk of aspiration; and the need to avoid drug addiction.
Medication Calculation: Calculate the proper amount of medication to administer based on the order and the strength of the available medication.
Spiritual Support: Provide feedback and encourage the spouse when they ask for help concerning their faith and support during this difficult time.
Sleep Disorder Intervention: Interventions should include observing for sleep disorders and documenting the observed symptoms. Include potential questions or concerns to the client.
Communication with Client: Encourage visitors to communicate with the client, suggesting the use of touch, while upholding privacy and respect.
Symptoms and Potential Treatment: Identify potential symptoms (hyperreflexia in legs and arms, mottling of hands and feet, increased urinary output, head turned away from light), and outline correct nursing interventions (provide support for emotional needs).
Advance Directives Explanation: Explain that a living will is often used by patients, because they may not be able to make their wishes known during an incapacitating event.
Client's Pain Management: Determine the etiology of the client's pain and anxiety, by using specific questioning, for example ask "On a scale of 0 to 10, how would you rate your pain?." Use observation to identify and document factors like frequent grimacing.
Pain Relief and Management: Provide instructions for managing pain (cold packs for swelling, and the usage of heating pads). Indicate that pain relief is not the same as curing the cause.
Medication Administration: Properly administer prescribed medicines, according to medication protocols, and safety guidelines; and make appropriate documentation, where needed.
Post-Operative Care: Delegate tasks to unlicensed assistive personnel (UAP), which are age appropriate, and related to the client's health condition.
Ethics: Nurse must consider ethical principles during situations involving patient care in order to provide the best quality possible experience. Confidentiality is essential when protecting patient privacy.
Pain Medication Considerations: Discuss the rationale behind combining medications, and explain to the client that taking combinations of pain relievers can assist with pain management. Also, point out that tolerance and addiction can occur.

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Description

This quiz covers essential nursing concepts related to choking assessment, advance directives, and client comfort. It emphasizes the evaluation of client situations and communication with healthcare providers for appropriate actions. Additionally, it highlights the importance of understanding and explaining the Patient Self-Determination Act to clients and their families.