A client severely injured in a motor vehicle accident is rushed to the health care facility with severe head injuries and profuse loss of blood. Which sign indicates approaching death?
The client's breathing becomes noisy. The client is calm and peaceful. The frequency of urination decreases. The ...
Practice Questions and Answers for
Exam 3 NUR 211
A client severely injured in a motor vehicle accident is rushed to the health care facility
with severe head injuries and profuse loss of blood. Which sign indicates approaching
death?
The client's breathing becomes noisy.
The client is calm and peaceful.
The frequency of urination decreases.
The arms and legs are warm to touch. ✅*Noisy breathing,* or death rattle, is common
during the final stages of dying because of the accumulation of secretions in the lungs.
Reduced urination is not seen during the final stages of dying. Instead, the client
develops loss of control over bladder and bowels due to loss of neurological control.
The peripheral parts of the client's body such as the arms and the legs are cold to touch
(not warm) because the circulation is directed away from the periphery and toward the
core of the body. Clients in the last stages of dying are usually not calm and peaceful;
they occasionally exhibit sudden restlessness due to hunger for oxygen.
A nurse attempts to count the respiratory rate of a client via inspection and finds that the
client is breathing at such a shallow rate that it cannot be counted. What is an
alternative method of determining the respiratory rate for this client?
Use a pulse oximeter to count the respirations for 1 minute.
Palpate the posterior thorax excursion, count respirations for 30 seconds, and multiply
by 2.
Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2.
Monitor arterial blood gas results for 1 minute. ✅Sometimes it is easier to count
respirations by *auscultating the lung sounds for 30 seconds and multiplying the result
by 2.* Palpating the posterior thorax excursion detects vibrations in the lungs. Pulse
oximeter and arterial blood gas results assess respiratory effectiveness, not respiratory
rate.
The nurse is instructing a client who is scheduled for a laryngectomy about methods of
laryngeal speech. Which best describes tracheoesophageal puncture (TEP)?
It will result in a low, gruff-sounding voice.
It enables the client to form words with the lips.
It requires the insertion of a prosthesis into the trachea.
It requires the client to hold a throat vibrator against the neck. ✅TEP requires a
surgical *opening in the posterior wall of the trachea, followed by the insertion of a
, prosthesis such as a Blom-Singer device*. An artificial larynx is a throat vibrator held
against the neck that projects sound into the mouth. With esophageal speech, the client
forms words with the lips. Esophageal speech causes the voice quality to be lower
pitched and gruff sounding.
Which ventilator mode provides full ventilatory support by delivering a present tidal
volume and respiratory rate?
Assist control
IMV
SIMV
Pressure support ✅*Assist-control ventilation* provides full ventilator support by
delivering a preset tidal volume and respiratory rate.
IMV provides a combination of mechanically assisted breaths and spontaneous
breaths.
SIMV delivers a preset tidal volume and number of breaths per minute. Between
ventilator-delivered breaths, the patient can breathe spontaneously with no assistance
from the ventilator for those extra breaths.
Pressure support ventilation assists SIMV by applying a pressure plateau to the airway
throughout the client-triggered inspiration to decrease resistance within the tracheal
tube and ventilator tubing.
The nurse is assisting a pregnant client who has just underwent a nonstress test that
was ruled reactive. Which factor will the nurse point out when questioned by the client
about the results?
A. The fetal heart rate increases with activity and indicates fetal well-being.
B. There is no evidence of congenital anomalies or deformities.
C. The results indicate a stress test is needed for further evaluation.
D. The fetus is developing at a fast rate but doing fine. ✅A
What would be the priority nursing diagnosis for a patient who is prescribed epoetin
alfa?
Alteration in bowel elimination due to side effects of the medication
Alteration in nutrition due to poor intake of iron
Altered skin integrity due to the disease process
Impaired tissue oxygenation related to anemia ✅The most appropriate priority nursing
diagnosis is impaired tissue oxygenation related to anemia. The other diagnoses are not
specific to the reason that epoetin is prescribed or the specific side effects of the
medication.
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