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Questions and Answers | Grade A |
100% Correct (Verified Solutions)
Question:
The nurse enters the client's room and introduces themself. They notice that
the client is lying flat on the bed and is crying. The client states, "I am so short
of breath that I just know I am going to die soon, and my family won't be here
with me." The nurse notices that the client's SpOz is now 89% on room air,
pulse is 102 beats/min, and respirations are 22 breaths/min.
Which of the following actions should the nurse plan to implement? (Select
all that apply)
Answer:
- Apply oxygen at 2 Lpm via nasal cannula.
- Assist the client with deep breathing exercises.
- Assess placement of oximeter sensor.
,Question:
Following interventions to relieve the client's respiratory status, the nurse
addresses the client's prior statement of "I just know I am going to die soon,
and my family won't be here with me."
Which of the following statements by the nurse indicate the use of
therapeutic communication? (Select all that apply)
Answer:
- "Do you have an advance directive if you are unable to make healthcare
decisions?"
- "You are worried that you will die and not see your family."
- "It must be very frightening to not have your family with you right now."
Question:
The nurse is planning care interventions to help the client reduce their stress
and anxiety.
Which of the following interventions should the nurse include in the client's
plan of care? (Select all that apply)
Answer:
- Facilitate the client's communication with family.
- Assist the client in using relaxation techniques.
- Provide a relaxing environment by reducing outside stressors.
- Ask the client if they would like to speak with the chaplain.
, Question:
The client remains on 2 Lpm via nasal cannula. Their SpOz is now 94%,
respiratory rate is 16 breaths/min, and the client is no longer reporting
shortness of breath. The nurse notices the client rubbing their nose and
pulling down the nasal cannula. The nurse asks the client if their nose is
bothering them and the client states, "My nose feels really dry and itchy."
Which of the following actions by the nurse are appropriate? (Select all that
apply)
Answer:
- Attach humidifier bottle to oxygen delivery system.
- Apply a water-soluble lubricant to the client's nares.
Question:
The nurse is delegating tasks to an unlicensed personnel (UP) who will be
assisting with the client's care.
Which of the following tasks should the nurse delegate to the UP? (Select all
that apply)
Answer:
- Document client's urine output in the electronic medical record.
- Assist the client with ambulation to the bathroom.
- Rotate client's oximeter sensor every 8 hrs.