Next-Generation NCLEX Exam Preparation Guide for 2024-2025, Exams of Nursing

Download Next-Generation NCLEX Exam Preparation Guide for 2024-2025 and more Exams Nursing in PDF only on Docsity! lOMoARcPSD| 40206794 NEXT-GENERATION NCLEX ACTUAL EXAM 2024-2025-with 100% verifi ed soluti ons -tutor verifi ed Oncotic pressure refers to the @ osmotic pressure exerted by proteins. excretion of substances such as glucose through increased urine output. number of dissolved particles contained in a unit of fluid. amount of pressure needed to stop the flow of water by osmosis. Correct Response: osmotic pressure exerted by proteins. Rationale: Oncotic pressure is a pulling pressure exerted by proteins such as albumin. Osmolality refers to the number of dissolved particles contained in a unit of fluid. Osmotic diuresis occurs when urine output increases as a result of excretion of substances such as glucose. Osmotic pressure is the amount of pressure needed to stop the flow of water by osmosis. Which condition might occur with respiratory acidosis? Decreased pulse @ Increased intracranial pressure Decreased blood pressure Mental alertness Correct Response: Increased intracranial pressure Rationale: If respiratory acidosis is severe, intracranial pressure may increase, resulting in papilledema and dilated conjunctival blood vessels. Increased blood pressure, increased pulse, and decreased mental alertness occur with respiratory acidosis.  The nurse is caring for a client with a serum potassium concentration of 6.0 mEq/L (6.0 mmol/L) and a fluid volume excess. The client is ordered to receive oral sodium polystyrene sulfonate and furosemide. What other order should the nurse anticipate giving? Increase the rate of the intravenous lactated Ringer solution. Change the lactated Ringer solution to 2.5% dextrose. Qe Discontinue the intravenous lactated Ringer solution. Change the lactated Ringer solution to 3% saline. Correct Response: Discontinue the intravenous lactated Ringer solution. Rationale: The lactated Ringer intravenous (IV) fluid is contributing to both the fluid volume excess and the hyperkalemia. In addition to the volume of IV fluids contributing to the fluid volume excess, lactated Ringer solution contains more sodium than daily requirements, and excess sodium worsens fluid volume excess. Lactated Ringer solution also contains potassium, which would worsen the hyperkalemia.  The nurse is caring for a client in the intensive care unit (ICU) following a near-drowning event in saltwater. The client is restless, lethargic, and demonstrating tremors. Additional assessment findings include swollen and dry tongue, flushed skin, and peripheral edema. The nurse anticipates that the client's serum sodium value would be 145 mEq/L (145 mmol/L) @ 155 mEq/L (155 mmol/L) 125 mEq/L (125 mmol/L) 135 mEq/L (135 mmol/L) Correct Response: 155 mEq/L (155 mmol/L) Rationale: The client is experiencing signs and symptoms (S/S) of hypernatremia. Hypernatremia is a serum sodium concentration >145 mEq/L (>145 mmol/L). A cause of hypernatremia is near drowning in seawater (which contains a sodium concentration of approximately 500 mEq/L). S/S of hypernatremia include thirst, elevated body temperature, swollen and dry tongue and sticky mucous membranes, hallucinations, lethargy, restlessness, irritability, simple partial or tonic-clonic seizures, pulmonary edema, hyperreflexia, twitching, nausea, vomiting, anorexia, elevated pulse, and elevated blood pressure.  When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis? @ pH7.48 O saturation 95% PaCO 36 HCO 21 mEq/L Correct Response: pH 7.48 Rationale: Metabolic alkalosis is a clinical disturbance characterized by a high pH and high plasma bicarbonate concentration. The HCO value is below normal. The PaCO value and the oxygen saturation level are within a normal range. Which is the preferred route of administration for potassium? Intramuscular IV (intravenous) push @ oral Subcutaneous Correct Response: Oral Rationale: When the client cannot ingest sufficient potassium by consuming foods that are high in potassium, administering oral potassium is ideal because oral potassium supplements are absorbed well. Administration by IV is done with extreme caution using an infusion pump, with the patient monitored by continuous ECG. To avoid replacing potassium too quickly, potassium is never administered by IV push or intramuscularly. Potassium is not administered subcutaneously.  The nurse has been assigned to care for various clients. Which client is at the highest risk for a fluid and electrolyte imbalance? A 45-year-old client who had a laparoscopic appendectomy 24 hours ago and is being advanced to a regular diet. @ An 82-year-old client who receives all nutrition via tube feedings and whose medications include carvedilol and torsemide. A 66-year-old client who had an open cholecystectomy with a T-tube placed that is draining 125 mL of bile per shift. A79-year-old client admitted with a diagnosis of pneumonia. Correct Response: An 82-year-old client who receives all nutrition via tube feedings and whose medications include carvedilol and torsemide. Rationale: The 82-year-old client has three risk factors: advanced age, tube feedings, and diuretic usage (torsemide). This client has the highest risk for fluid and electrolyte imbalances. The 45-year- old client has the risk factor of surgery, the 79-year-old client has the risk factor of advanced age, and the 66-year-old client has the risk factors of age and the bile drain, but none of these are the client at the highest risk.  The nurse is caring for a patient with a metabolic acidosis (pH 7.25). Which of the following values is useful to the nurse in determining whether the cause of the acidosis is due to acid gain or to bicarbonate loss? @ Anion gap PaCOz Serum sodium level Bicarbonate level Correct Response: Anion gap Rationale: Metabolic acidosis is a common clinical disturbance characterized by a low pH (increased H* concentration) and a low plasma bicarbonate concentration. It can be produced by a gain of hydrogen ion or a loss of bicarbonate. It can be divided clinically into two forms, according to the values of the serum anion gap: high anion gap acidosis and normal anion gap acidosis. A patient diagnosed with metabolic acidosis is determined to have normal anion gap metabolic acidosis if the anion gap is within this normal range. An anion gap greater than 16 mEq (16 mmol/L) (the normal value for an anion gap is 8-12 mEq/L (8-12 mmol/L) without potassium in the equation. If potassium is included in the equation, the normal value for the anion gap is 12-16 mEq/L (12-16 mmol/L) and suggests an excessive accumulation of unmeasured anions and would indicate high anion gap metabolic acidosis as the type. An anion gap occurs because not all electrolytes are measured. More anions are left unmeasured than cations. A low or negative anion gap may be attributed to hypoproteinemia. Disorders that cause a decreased or negative anion gap are less common compared to those related to an increased or high anion gap.  At which serum sodium concentration might convulsions or coma occur? 145 mEq/L (145 mmol/L) 142 mEq/L (142 mmol/L) @ 130 mEq/L (130 mmol/L) 140 mEq/L (140 mmol/L) Correct Response: 130 mEq/L (130 mmol/L) Rationale: Normal serum concentration level ranges from 135 to 145 mEq/L (135-145 mmol/L). When the level dips below 135 mEq/L (135 mmol/L), hyponatremia occurs. Manifestations of hyponatremia include mental confusion, muscular weakness, anorexia, restlessness, elevated body temperature, tachycardia, nausea, vomiting, and personality changes. Convulsions or coma can occur if the deficit is severe. Values of 140, 142, and 145 mEq/L (mmol/L) are within the normal range.  When caring for a client who has risk factors for fluid and electrolyte imbalances, which assessment finding is the highest priority for the nurse to follow up? Weight loss of 4 Ib Mild confusion Blood pressure 96/53 mm Hg @ irregular heart rate Correct Response: irregular heart rate Rationale: Irregular heart rate may indicate a potentially life-threatening cardiac dysrhythmia. Potassium, magnesium, and calcium imbalances may cause dysrhythmias. Weight loss is a good indicator of the amount of fluid lost, confusion may occur with dehydration and hyponatremia, and blood pressure is slightly lower than normal (though not life threatening); in each case, following up on potential cardiac dysrhythmias is a higher priority. The nurse is caring for a client undergoing alcohol withdrawal. Which serum laboratory value should the nurse monitor most closely? Potassium Calcium @ Magnesium Phosphorus Correct Response: Magnesium Rationale: Chronic alcohol abuse is a major cause of symptomatic hypomagnesemia in the United States. The serum magnesium concentration should be measured at least every 2 or 3 days in clients undergoing alcohol withdrawal. The serum magnesium concentration may be normal at admission but may decrease as a result of metabolic changes, such as the intracellular shift of magnesium associated with intravenous glucose administration.  Which condition leads to chronic respiratory acidosis in older adults? Overuse of sodium bicarbonate @ Thoracic skeletal change Decreased renal function Erratic meal patterns Correct Response: Thoracic skeletal change Rationale: Poor respiratory exchange as the result of chronic lung disease, inactivity, or thoracic skeletal changes may lead to chronic respiratory acidosis. Decreased renal function in older adults can cause an inability to concentrate urine and is usually associated with fluid and electrolyte imbalance. A poor appetite, erratic meal patterns, inability to prepare nutritious meals, or financial circumstances may influence nutritional status, resulting in imbalances of electrolytes. Overuse of sodium bicarbonate may lead to metabolic alkalosis.  The nurse is instructing a client with recurrent hyperkalemia about following a potassium- restricted diet. Which statement by the client indicates the need for additional instruction? @ "Iwill not salt my food; instead I'll use salt substitute." "| need to check to see whether my cola beverage has potassium in it.” "Tl drink cranberry juice with my breakfast instead of coffee." "Bananas have a lot of potassium in them; I'll stop buying them." Correct Response: "! will not salt my food; instead I'll use salt substitute." Rationale: The client should avoid salt substitutes. The nurse must caution clients to use salt substitutes sparingly if they are taking other supplementary forms of potassium or potassium-conserving diuretics. Potassium-rich foods to be avoided include many fruits and vegetables, legumes, whole-grain breads, lean meat, milk, eggs, coffee, tea, and cocoa. Conversely, foods with minimal potassium content include butter, margarine, cranberry juice or sauce, ginger ale, gumdrops or jellybeans, hard candy, root beer, sugar, and honey. Labels of cola beverages must be checked carefully because some are high in potassium and some are not.  Anurse is caring for a client with acute renal failure and hypernatremia. In this case, which action can be delegated to the nursing assistant? g Provide oral care every 2-3 hours. Teach the client about increased fluid intake. Monitor for signs and symptoms of dehydration. Assess the client's weight daily for trends. Correct Response: Provide oral care every 2-3 hours. Rationale: Providing oral care for the client every 2-3 hours is within the scope of practice of a nursing assistant. The other actions should be completed by the registered nurse. The nurse is analyzing the electrocardiographic (ECG) rhythm tracing of a client experiencing hypercalcemia. Which ECG change is typically associated with this electrolyte imbalance? Prolonged QT intervals @ Prolonged PR intervals Elevated ST segments Peaked T waves Correct Response: Prolonged PR intervals Rationale: Cardiovascular changes associated with hypercalcemia may include a variety of dysrhythmias (e.g., heart blocks) and shortening of the QT interval and the ST segment. The PR interval is sometimes prolonged. The other changes are not associated with an elevated serum calcium concentration.  Which is an insensible mechanism of fluid loss? Urination Bowel elimination Nausea 8 Breathing Correct Response: Breathing Rationale: Insensible perspiration is a nonvisible form of water loss from the body. The lungs (breathing) eliminate water vapor creating an insensible loss. Losses from urination and bowel elimination are observable or sensible. Nausea does not result in fluid loss, however, if the client would develop emesis ( vomiting) this would be considered loss of body fluids and could be observed and measured.  The nurse is analyzing the arterial blood gas (ABG) results of a client diagnosed with severe pneumonia. Which of the following ABG results indicates respiratory acidosis? pH: 7.32, PaCO,: 40 mm Hg, HCO3_: 18 mEq/L pH: 7.50, PaCOz: 30 mm Hg, HCO3_: 24 mEq/L @ pH: 7.20, PaCO.: 65 mm Hg, HCO3_: 26 mEq/L pH: 7.40, PaCOz: 40 mm Hg, HCO3_: 24 mEq /L Correct Response: pH: 7.20, PaCOs: 65 mm Hg, HCO3_: 26 mEq/L Rationale: Respiratory acidosis is a clinical disorder in which the pH is less than 7.35-7.40 and the PaCO2 is greater than 40-45 mm Hg and a compensatory increase in the plasma HCO3_ occurs. Respiratory acidosis may be either acute or chronic. The ABG of pH: 7.32, PaCOz: 40 mm Hg, HCO3_: 18 mEq/L indicates metabolic acidosis. The ABGs of pH: 7.50, PaCO»: 30 mm Hg, and HCO3_: 24 mEq/L indicate respiratory alkalosis. The ABGs of pH 7.40, PaCO2: 40 mm Hg, and HCO3_: 24 mEq/L indicate a normal result/no imbalance.  The nurse is assessing a client for local complications of intravenous therapy. Which are local complications? Select all that apply. Air embolism 6 Extravasation 6 Hematoma @ Phiebitis @ Infection Correct Response: Extravasation , Hematoma , Phlebitis , Infection Rationale: Local complications of intravenous therapy include infiltration and extravasation, phlebitis, thrombophlebitis, hematoma, and clotting of the needle. Infections can be local or systemic. Systemic complications occur less frequently but are usually more serious than local complications and include circulatory overload, air embolism, and febrile reaction.  The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium concentration of 2.9 mEq/L (2.9 mmol/L). Which statement made by the client indicates the need for further teaching? "A good breakfast for me will include milk and a couple of bananas.” 6 "| can use laxatives and enemas but only once a week." "| will take a potassium supplement daily as prescribed." "| will be sure to buy frozen vegetables when | grocery shop." Correct Response: "/ can use laxatives and enemas but only once a week." Rationale: The client is experiencing hypokalemia, most likely due to the diagnosis of bulimia. Hypokalemia is defined as a serum potassium concentration <3.5 mEq/L (3.5 mmol/L), and usually indicates a deficit in total potassium stores. Clients diagnosed with bulimia frequently suffer increased potassium loss through self-induced vomiting and misuse of laxatives, diuretics, and enemas; thus, the client should avoid laxatives and enemas. Prevention measures may involve encouraging the client at risk to eat foods rich in potassium (when the diet allows), including fruit juices and bananas, melon, citrus fruits, fresh and frozen vegetables, lean meats, milk, and whole grains. If the hypokalemia is caused by abuse of laxatives or diuretics, client education may help alleviate the problem. Chapter 11  Which pulse pressure indicates shock? @ 90/70 mm HG 130/80 mm HG 420/90 mm HG 100/60 mm HG Correct Response: 90/70 mm HG Rationale: Pulse pressure correlates with stroke volume. Elevation of the diastolic BP with the release of catecholamines and attempts to increase venous return through vasoconstriction is an early compensatory mechanism in response to decreased stroke volume. A narrowed or decreased pulse pressure is an early indicator of shock. A normal pulse pressure is 40 mm Hg (120 mm Hg systolic blood pressure minus 80 mm Hg diastolic blood pressure); thus 90/70 = 20 mm HG, indicates a narrowed pulse pressure. 130 mm HG -80 mm HG = 50 mm HG, a normal pulse pressure. 100 mm HG- 60 mm HG = 40 mm HG- a normal pulse pressure. Which colloid is expensive but rapidly expands plasma volume? @ Albumin Hypertonic saline Lactated Ringer solution Dextran Correct Response: Albumin Rationale: Albumin is a colloid that requires human donors, is limited in supply, and can cause congestive heart failure. Dextran interferes with platelet aggregation and is not recommended for hemorrhagic shock. Lactated Ringer solution and hypertonic saline are crystalloids, not colloids.  Aclient presents to the emergency department with her spouse. The client appears to be in respiratory distress. The spouse states, "| think she ate a dessert made with peanuts; she's allergic to peanuts." The nurse should administer which agent first? Albuterol nebulizer IV infusion of normal saline Diphenhydramine IV © Epinephrine intramuscularly Correct Response: Epinephrine intramuscularly Rationale: All of the interventions are indicated in the treatment of anaphylactic shock. However, IM epinephrine is administered first because of its vasoconstrictive action. |V Diphenhydramine is administered to reverse the effects of histamine, thereby reducing capillary permeability. Nebulized medications such as albuterol may be given to reverse histamine-induced bronchospasm. Fluid management is critical, as massive fluid shifts can occur within minutes due to increased vascular permeability. Which type of shock is caused by an infection? @ Septic Cardiogenic Hypovolemic Anaphylactic Correct Response: Septic Rationale: Septic shock is caused by an infection. Cardiogenic shock occurs when the heart has an impaired pumping ability. Hypovolemic shock occurs when the intravascular volume has decreased. Anaphylactic shock is caused by a hypersensitivity reaction.  Vasoactive drugs, which cause the arteries and veins to dilate, thereby shunting much of the intravascular volume to the periphery and causing a reduction in preload and afterload, include agents such as dopamine. furosemide. © sodium nitroprusside. norepinephrine. Correct Response: sodium nitroprusside. Rationale: Sodium nitroprusside is a vasodilater used in the treatment of cardiogenic shock. Norepinephrine is a vasopressor that is used to promote perfusion to the heart and brain. Dopamine tends to increase the workload of the heart by increasing oxygen demand; thus, it is not administered early in the treatment of cardiogenic shock. Furosemide is a loop diuretic that reduces intravascular fluid volume. When a client is in the compensatory stage of shock, which symptom occurs? @ Tachycardia Urine output of 45 cc/hour Respiratory acidosis Bradycardia Correct Response: Tachycardia Rationale: The compensatory stage of shock encompasses a normal blood pressure, tachycardia, decreased urinary output, confusion, and respiratory alkalosis.  Which type of shock occurs from an antigen-antibody response? Neurogenic @ Anaphylactic Septic Cardiogenic Correct Response: Anaphylactic Rationale: During anaphylactic shock, an antigen-antibody reaction provokes mast cells to release potent vasoactive substances, such as histamine or bradykinin, causing widespread vasodilation and capillary permeability. Septic shock is a circulatory state resulting from overwhelming infection causing relative hypovolemia. Neurogenic shock results from loss of sympathetic tone causing relative hypovolemia. Cardiogenic shock results from impairment or failure of the myocardium. The nurse is caring for a client in cardiogenic shock. The client weighs 90 kg. A dobutamine drip at 1 yg/kg/min is ordered. The dobutamine is supplied in a concentration of 500 mg in 250 mL DSW. IV infusion should be started at how many milliliters per hour? 11 mL/hr. 5.5 mL/hr @ 2.7 mUhr 8.0 mL/hr Correct Response: 2.7 mL/hr Rationale: The nurse should administer 2.7 mL/hr: 1 mcg/90 kg/60 minutes/2,000 (concentration)  The nurse anticipates that a client who is immunosuppressed is at the greatest risk for developing which type of shock? Anaphylactic Cardiogenic Neurogenic @ Septic Correct Response: Septic Rationale: Septic shock is associated with immunosuppression, extremes of age, malnourishment, chronic illness, and invasive procedures. Neurogenic shock is associated with spinal cord injury and anesthesia. Cardiogenic shock is associated with disease of the heart. Anaphylactic shock is associated with hypersensitivity reactions. Which drug is a vasodilator used in the treatment of shock? Qe Nitroglycerin Dopamine Debutamine Norepinephrine Correct Response: Nitroglycerin Rationale: Nitroglycerin is a vasodilator used to reduce preload and afterload and reduce oxygen demand of the heart. Dopamine and dobutamine are sympathomimetic and are used to improve contractility, increase stroke volume, and increase cardiac output. Norepinephrine is a vasoconstrictor used to increase blood pressure by vasoconstriction.  Which stage of shock encompasses mechanical ventilation, altered level of consciousness, and profound acidosis? 8 Irreversible Precompensatory Compensatory Progressive Correct Response: Irreversible Rationale: The irreversible stage encompasses use of mechanical ventilation, altered consciousness, and profound acidosis. The compensatory stage encompasses decreased urinary output, confusion, and respiratory alkalosis. The progressive stage involves metabolic acidosis, lethargy, and rapid, shallow respirations. There is not a stage of shock called the precompensatory stage. Which positioning strategy should be used for a client diagnosed with hypovolemic shock? Prone eo Modified Trendelenburg Supine Semi-Fowler Correct Response: Modified Trendelenburg Rationale: Amodified Trendelenburg position is recommended in hypovolemic shock. Elevation of the legs promotes the return of venous blood and can be used as a dynamic assessment of a client's fluid responsiveness.  The nurse is caring for a 78-year-old client with extensive cardiovascular disease. Which type of shock is the client most likely to develop? © Cardiogenic shock Neurogenic shock Anaphylactic shock Septic shock Correct Response: Cardiogenic shock Rationale: Cardiogenic shock occurs when the heart's ability to contract and to pump blood is impaired and the supply of oxygen is inadequate for the heart and the tissues. Older adults, particularly those with cardiac disease, are susceptible to cardiogenic shack. Older adults are not susceptible to developing neurogenic, septic, or anaphylactic shock. Which stage of shock is best described as that stage when the mechanisms that regulate blood pressure fail to sustain a systolic pressure above 90 mm Hg? @ Progressive Irreversible Refractory Compensatory Correct Response: Progressive Rationale: In the progressive stage of shock, the mechanisms that regulate blood pressure can no longer compensate, and the mean arterial pressure falls below normal limits. The refractory or irreversible stage of shock represents the point at which organ damage is so severe that the client does not respond to treatment and cannot survive. In the compensatory state, the client's blood pressure remains within normal limits due to vasoconstriction, increased heart rate, and increased contractility of the heart.  The nurse is caring for a client in the early stages of sepsis. The client is not responding well to fluid resuscitation measures and has a worsening hemodynamic status. Which nursing intervention is most appropriate for the nurse to implement? Begin a continuous IV infusion of insulin per protocol. Initiate enteral feedings as prescribed. 6 Administer norepinephrine as prescribed. Administer recombinant human activated protein C (rhAPC) as prescribed. Correct Response: Administer norepinephrine as prescribed. Rationale: Vasopressor agents are used if fluid resuscitation does not restore an effective blood pressure and cardiac output. Norepinephrine centrally administered is the initial vasopressor of choice. Ongoing research has found that rhAPC does not positively affect the outcome of clients with severe sepsis and it is no longer available for use. IV insulin may be implemented to treat hyperglycemia but is not indicated to improve hemodynamic status. Enteral feedings are recommended but not to improve hemodynamic status.  Clinical characteristics of neurogenic shock are noted by which type of stimulation? Qe Parasympathetic Endocrine Sympathetic Cerebral Correct Response: Parasympathetic Rationale: The clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. Sympathetic stimulation causes vascular smooth muscle to constrict, and parasympathetic stimulation causes vascular smooth muscle to relax or dilate. The client experiences a predominant parasympathetic stimulation that causes vasodilation lasting for an extended period, leading to a relative hypovolemic state. It is not characterized by sympathetic, endocrine, or cerebral stimulation.  Aclient is admitted to the emergency department after a motorcycle accident. Upon assessment, the client's vital signs reveal blood pressure of 80/60 mm Hg and heart rate of 145 beats per minute. The client's skin is coal and clammy. Which medical order for this client will the nurse complete first? @ 100% oxygen via a nonrebreather mask Two large-bore IVs and begin crystalloid fluids Type and cross match C-spine x-rays Correct Response: 100% oxygen via a nonrebreather mask Rationale: The management in all types and all phases of shock includes the following: support of the respiratory system with supplemental oxygen and/or mechanical ventilation to provide optimal oxygenation, fluid replacement to restore intravascular volume, vasoactive medications to restore vasomotor tone and improve cardiac function, and nutritional support to address metabolic requirements that are often dramatically increased in shock. The first priority in the initial management of shock is maintenance of the airway and ventilation; thus, 100% oxygen should be applied via a nonrebreather mask. The other orders should be completed after the client's airway is secure.  Which blood pressure (BP) reading would result in a pulse pressure indicative of shock? © 90/70 mm Hg 100/60 mm Hg 130/90 mm Hg 120/90 mm Hg Correct Response: 90/70 mm Hg Rationale: Pulse pressure is calculated by subtracting the diastolic measurement from the systolic measurement; the difference is the pulse pressure. Anormal pulse pressure is 30 to 40 mm Hg. Narrowing or decreased pulse pressure is an earlier indicator of shock than a drop in systolic BP. ABP reading of 90/70 mm Hg indicates a narrowing pulse pressure.  The nurse is caring for a client with a central venous line in place for the treatment of shock. Which nursing interventions are essential for the nurse to complete in order to reduce the risk of infection? Select all that apply. @ Apply clean gloves before accessing the line port. @ Maintain sterile technique when changing the central venous line dressing. Instruct the client to wear a face mask and gloves while the central venous line is in place. Perform a 10-second "hub scrub" using chlorhexidine and friction in a twisting motion on the access hub. [7] Always perform hand hygiene before manipulating or accessing the line ports. Correct Response: Apply clean gloves before accessing the line port. Maintain sterile technique when changing the central venous line dressing. Always perform hand hygiene before manipulating or accessing the line ports. Rationale: The following nursing interventions are essential to reduce the risk of infection: maintain sterile technique when changing the central venous line dressing; always perform hand hygiene before manipulating or accessing the line ports; apply clean gloves before accessing the line port; and perform a 15- to 30-second "hub scrub" using chlorhexidine or alcohol and friction in a twisting motion on the access hub. The latter reduces biofilm on the hub that may contain pathogens. Chapter 12  The nurse is providing education to a client with cancer radiation treatment options. The nurse determines that the client understands the teaching when the client states that which type of radiation aims to protect healthy tissue during the treatment? External Teletherapy Proton therapy @ Brachytherapy Correct Response: Brachytherapy Rationale: In internal radiation, or brachytherapy, a dose of radiation is delivered to a localized area inside the body through the use of an implant. With this type of therapy, the farther the tissue is from the radiation source, the lower the dose. This helps to protect normal tissue from the radiation therapy. Adecrease in circulating white blood cells (VWBCs) is referred to as Neutropenia Granulocytopenia 8 Leukopenia Thrombocytopenia Correct Response: Leukopenia Rationale: Adecrease in circulating WBCs is referred to as leukopenia. Granulocytopenia is a decrease in neutrophils. Thrombocytopenia is a decrease in the number of platelets. Neutropenia is an abnormally low absolute neutrophil count.  Adecrease in circulating white blood cells is granulocytopenia. neutropenia. © leukopenia. thrombocytopenia. Correct Response: leukopenia. Rationale: Adecrease in circulating WBCs is referred to as leukopenia. Granulocytopenia is a decrease in neutrophils. Thrombocytopenia is a decrease in the number of platelets. Neutropenia is an abnormally low absolute neutrophil count. Which type of vaccine uses the client's own cancer cells, which are killed and prepared for injection back into the client? Allogeneic @ Autologous Therapeutic Prophylactic Correct Response: Autologous Rationale: Autologous vaccines are made from the client's own cancer cells, which are obtained during diagnostic biopsy or surgery. Prophylactic vaccines, such as the polio vaccine, are given to prevent people from developing a disease. Therapeutic vaccines are given to kill existing cancer cells and to provide long-lasting immunity against further cancer development. Allogeneic vaccines are made from cancer cells that are obtained from other people who have a specific type of cancer.  After a bone marrow transplant (BMT), the client should be monitored for at least 60 days @ 100 days 14 days 30 days Correct Response: 100 days Rationale: After a BMT, the nurse closely monitors the client for at least 100 days or more after the procedure because complications related to the transplant can occur 100 days or more as post procedure infections are one common complication that may lead to sepsis and transplant failure. The physician is attending to a 72-year-old client with a malignant brain tumor. The physician recommends immediate radiation therapy. What is a reason for the physician's recommendation? To analyze the lymph nodes involved 6 To prevent the formation of new cancer cells To destroy marginal tissues To remove the tumor from the brain Correct Response: To prevent the formation of new cancer cells Rationale: Radiation therapy helps prevent cellular growth. It may be used to cure the cancer or to control malignancy when the tumor cannot be removed or when lymph node involvement is present; also, it can be used prophylactically to prevent spread. Biopsy is used to analyze lymph nodés or to destroy the surrounding tissues around the tumor.  Which class of antineoplastic agents is cell cycle-specific? © Antimetabolites (5-FU) Nitrosoureas (carmustine) Antitumor antibiotics (bleomycin) Alkylating agents (cisplatin) Correct Response: Antimetabolites (5-FU) Rationale: Antimetabolites are cell cycle—specific (S phase). Antitumor antibiotics, alkylating agents, and nitrosoureas are cell cycle-nonspecific. A benign tumor of the blood vessels is a(n) chondroma. @ hemangioma. neuroma. osteoma. Correct Response: hemangioma. Rationale: Ahemangioma is a benign tumor of the blood vessels. An osteoma is a tumor of the connective tissue. A neuroma is a tumor of the nerve cells. A chondroma is a tumor of the cartilage.  According to the tumor-node-metastasis (TNM) classification system, TO means there is @ No evidence of primary tumor Distant metastasis No regional lymph node metastasis No distant metastasis Correct Response: No evidence of primary tumor Rationale: TO means that there is no evidence of primary tumor. NO means that there is no regional lymph node metastasis. MO means that there is no distant metastasis. M1 means that there is distant metastasis.  The nurse is preparing to assess a client whose chart documents that the client experienced extravasation when receiving the vesicant vincristine during the previous shift. The documentation also notes that an antidote was administered immediately. The nurse prepares to assess for which conditions? Select all that apply. Active bleeding @ Sloughing tissue @ Tissue necrosis o Effectiveness of the antidote Correct Response: Sloughing tissue , Tissue necrosis Effectiveness of the antidote Rationale: Extravasation of vesicant chemotherapeutic agents can lead to erythema, sloughing, and necrosis of surrounding tissue, muscle, and tendons. To reduce the likelihood and severity of symptoms due to extravasation of a vesicant, antidotes matched to the vesicant are administered. Nurses caring for a client who experienced extravasation of a vesicant should assess for sloughing tissue, tissue necrosis, erythema, and effectiveness of the antidote.  According to the TNM classification system, TO means there is @ no evidence of primary tumor. distant metastasis. no distant metastasis. no regional lymph node metastasis. Correct Response: no evidence of primary tumor. Rationale: TO means that there is no evidence of primary tumor. NO means that there is no regional lymph node metastasis. MO means that there is no distant metastasis. M1 means that there is distant metastasis. Acclient with metastatic pancreatic cancer underwent surgery to remove a malignant tumor in the pancreas. Despite the tumor being removed, the physician informs the client that chemotherapy must be started. Why might the physician opt for chemotherapy? Stomatitis 6 To prevent metastasis Fatigue Angiogenesis Correct Response: To prevent metastasis Rationale: Chemotherapy treats systemic and metastatic cancer. It can also be used to reduce tumor size preoperatively, or to destroy any remaining tumor cells postoperatively. Angiogenesis is the growth of new capillaries from the tissue of origin. This process helps malignant cells obtain needed nutrients and oxygen to promote growth. Fatigue and stomatitis are side effects of radiation and chemotherapy.  Which does a nurse thoroughly evaluate before a hematopoietic stem cell transplant (HSCT) procedure? Family history Drug history Allergy history @ Blood studies Correct Response: Blood studies Rationale: Before the HSCT procedure, the nurse thoroughly evaluates the client's physical condition; organ function; nutritional status; complete blood studies, including assessment for past exposure to antigens such as HIV, hepatitis, or cytomegalovirus; and psychosocial status. Before an HSCT procedure, the nurse need not evaluate client's family, drug, or allergy history. The nurse is conducting a screening for familial predisposition to cancer. Which element should the nurse note as a possible indication of hereditary cancer syndrome? Asecond cousin diagnosed with cancer A first cousin diagnosed with cancer e@ An aunt and uncle diagnosed with cancer Onset of cancer after age 50 in family member Correct Response: An aunt and uncle diagnosed with cancer Rationale: The hallmarks of hereditary cancer syndrome include cancer in two or more first-degree or second-degree relatives, early onset of cancer in family members younger than age 50, the same type of cancer in several family members, individual family members with more than one type of cancer, and a rare cancer in one or more family members.  The nurse is caring for a client undergoing an incisional biopsy. Which statement does the nurse understand to be true about an incisional biopsy? @ It removes a wedge of tissue for diagnosis. Itis used to remove cancerous cells using a needle. It treats cancer with lymph node involvement. It removes an entire lesion and the surrounding tissue. Correct Response: It removes a wedge of tissue for diagnosis. Rationale: The three most common biopsy methods are excisional, incisional, and needle. In an incisional biopsy, a wedge of tissue is removed from the tumor and analyzed. In an excisional biopsy, the surgeon removes the tumor and the surrounding marginal tissues. Needle aspiration biopsy involves aspirating tissue fragments through a needle guided into the cancer cells.  Which should a nurse thoroughly evaluate before a bone marrow transplant (BMT) procedure? Family history 8 Blood studies Allergy history Drug history Correct Response: Blood studies Rationale: Before the BMT procedure, the nurse thoroughly evaluates the client's physical condition; organ function; nutritional status; complete blood studies, including assessment for past exposure to antigens such as HIV, hepatitis, or cytomegalovirus; and psychosocial status. Before a BMT procedure, the nurse need not evaluate the client's family, drug, or allergy history. The nurse is caring for a client with cancer who is treating her cancer with deep-tissue massage in addition to radiation therapy. The nurse documents the use of which therapy on the client's chart? Global medicine @ Integrative medicine Compliant medicine Alternative therapy Correct Response: Integrative medicine Rationale: Integrative medicine is the use of therapies in conjunction with conventional medicine. This is also known as complementary medicine. Alternative therapies are used instead of conventional medicine.  The nurse is conducting a community education program using the American Cancer Society's colorectal screening and prevention guidelines. The nurse determines that the participants understand the teaching when they identify that people over the age of 50 should have which screening test every 10 years? Fecal occult blood test @ Colonoscopy Papanicolaou (Pap) Prostate-specific antigen (PSA) Correct Response: Colonoscopy Rationale: Recommendations for screening for colorectal cancer include a screening colonoscopy every 10 years. Fecal occult blood tests should be completed annually in people over age 50. The test for PSA is used as a screening tool for prostate cancer. A Pap test is a screening tool for cervical cancer.  The nurse is working with a client who has had an allo-hematopoietic stem cell transplant (HSCT). The nurse notices a diffuse rash and diarrhea. The nurse contacts the physician to report that the client has symptoms of Qo graft-versus-host disease. metastasis. acute leukopenia. nadir. Correct Response: graft-versus-host disease. Rationale: Graft-versus-host disease is a major cause of morbidity and mortality in clients who have had allogeneic transplant. Clinical manifestations of the disease include diffuse rash that progresses to blistering and desquamation, and mucosal inflammation of the eyes and the entire gastrointestinal tract with subsequent diarrhea, abdominal pain, and hepatomegaly. The nurse is caring for a client with a benign breast tumor. The tumor may have which characteristic? Ability to invade other tissues @ Slow rate of growth Undifferentiated cells Causes generalized symptoms Correct Response: Slow rate of growth Rationale: Benign tumors have a slow rate of growth and well-differentiated cells. Benign tumors do not invade surrounding tissue and do not cause generalized symptoms unless the location of the tumor interferes with the functioning of vital organs.  Which type of surgery is used in an attempt to relieve complications of cancer? Reconstructive Prophylactic © Palliative Salvage Correct Response: Palliative Rationale: Palliative surgery is performed to relieve complications of cancer. Prophylactic surgery involves removing nonvital tissues or organs that are likely to develop cancer. Reconstructive surgery may follow curative or radical surgery and is carried out in an attempt to improve function or to obtain a more desirable cosmetic effect. Salvage surgery is an additional treatment option that uses an extensive surgical approach to treat the local recurrence of a cancer after the use of a less extensive primary approach. Which statement is true about malignant tumors? eo They gain access to the blood and lymphatic channels. They usually grow slowly. They demonstrate cells that are well differentiated. They grow by expansion. Correct Response: They gain access to the blood and lymphatic channels. Rationale: By gaining access to blood and lymphatic channels, a tumor can metastasize to other areas of the body. Cells of malignant tumors are undifferentiated. Malignant tumors demonstrate variable rates of growth; however, the more anaplastic the tumor, the faster its growth. A malignant tumor grows at the periphery and sends out processes that infiltrate and destroy surrounding tissues.  Aclient with a brain tumor recently stopped radiation and chemotherapy for treatment of the cancer. The client recently reported dry mouth. Which intervention by the hospice nurse demonstrates that the nurse understands treatment measures for dry mouth? Se Provide gentle oral care after each meal. Begin 9% normal saline IV at 125 mL/hr. Gently suction the client's mouth and buccal cavity. Place two drops of atropine ophthalmic 1% solution sublingually. Correct Response: Provide gentle oral care after each meal. Rationale: Dry mouth can generally be managed through nursing measures such as mouth care. The use of artificial hydration (IV fluids) carries considerable risks and does not contribute to comfort at the end of life. Atropine ophthalmic 1% drops administered sublingually help to reduce oral secretions. Gentle oral suctioning reduces the production of secretions.  Aclient in hospice has end-stage renal failure. The client states that, of late, he has lost his appetite and feels like everyday situations have become more stressful. The client reports feeling restless. In addition, the client's spouse notices that the client is becoming more confused. What is the most important nursing intervention that needs to be carried out at this point? Immediately administer drug therapy to restore renal function. @ Provide the spouse with an emergency kit that contains small doses of oral morphine liquid. Make arrangements with the physician to administer immunosuppressants. Make arrangements for the client to receive nutritional counseling. Correct Response: Provide the spouse with an emergency kit that contains small doses of oral morphine liquid. Rationale: One of the most important aspects of the care of a client at the end of life is anticipating and planning interventions for symptoms. Both clients and family members cope more effectively with new symptoms and exacerbations of existing symptoms when they know what to expect and how to manage them. Nutritional counseling, involving the family in the plan of care, and providing psychosocial support to the client are all relevant nursing interventions that form a part of the nursing management process for a client with chronic renal failure. Nutritional counseling, administration of drug therapy to restore renal functions, and administration of immunosuppressant drugs are medical management tasks.  Which term is used to describe the personal feelings that accompany an anticipated or actual loss? Mourning @ Grief Spirituality Bereavement Correct Response: Grief Rationale: Grief is defined as the personal feelings that accompany an anticipated or actual loss. Bereavement is a period during which mourning for a loss take place. Mourning is an expression of grief and associated behaviors. Spirituality is a personal belief system that focuses on a search for meaning and purpose of life. According to Kiibler-Ross, when a dying client pleas for more time to reach an important goal, the client is in which state of grief? @ Bargaining Anger Denial Acceptance Correct Response: Bargaining Rationale: Bargaining occurs when a client and/or family pleads for more time to reach an important goal. Anger includes feelings of rage or resentment. Denial includes feelings of isolation. Acceptance occurs when the client and/or family are neither angry nor depressed.  Aclient is declared to have a terminal illness. What intervention will a nurse perform related to the final decision of a dying client? Share emotional pain. @ Respect the client's and family members’ choices. Abide by the dying client's wishes. Ask the family members about spiritual care. Correct Response: Respect the client's and family members’ choices. Rationale: In the final decisions of a dying client, the nurse will present options for terminal care and respect the client's and family members’ choices. Sharing emotional pain is a role in providing care and comfort to dying clients and their families. When the client has a living will, physicians must abide by the client's wishes. The nurse should ask the family members about spiritual care only if the client wants someone associated with his or her religion.  The family members of a dying client are finding it difficult to verbalize their feelings for and show tenderness to the client. Which intervention should a nurse perform in such a situation? Encourage conversations about the impending death of the client 6 Encourage the family members to express their feelings and listen to them in their frank communication Be a silent observer and allow the client to communicate with the family members Encourage the client's family members to spend time with the client Correct Response: Encourage the family members to express their feelings and listen to them in their frank communication Rationale: Family members usually find it difficult to communicate frankly with a dying person. When a nurse encourages family members to express their feelings and listens to them as they frankly communicate, family members may feel more prepared to carry on a similarly honest dialogue with the dying client. It is not advisable for the nurse to encourage conversations about the impending death of the client. Being a silent observer or encouraging the family members to spend time with the dying client may not help the family members express their feelings.  During a home care visit to a client in hospice, the client's spouse reveals to the nurse an understanding that the client's death is inevitable. Recognizing the spouse is exemplifying the Kibler-Ross stage of acceptance, which statement by the nurse is most appropriate? "Make sure you have made previous arrangements with the funeral home for burial arrangements." "Have you thought about what you will do when you find your spouse after he has died?" 6 "Tell me how you plan to react when you first realize that your spouse is breathless and has no pulse." “| would make arrangements to have all your children present for the death vigil." Correct Response: “Teil me how you plan fo react when you first realize that your spouse is breathless and has no pulse." Rationale: Anticipating and planning interventions is a cornerstone of end-of-life care. The nurse encourages communication and anticipatory grieving by using open-ended statements such as "Tell me... ." Effective communication techniques include the avoidance of closed-ended statements and giving advice.  The physician is attending to a 72-year-old client with a malignant brain tumor. Family members report that the client rarely sleeps and frequently reports seeing things that are not real. Which intervention is an appropriate request for the hospice nurse to suggest to the physician? Perform surgery to remove the tumor from the brain. @ Add haloperidol to the client's treatment plan. Begin radiation therapy to prevent cellular growth. Obtain a biopsy to analyze the lymph nodes. Correct Response: Add haloperidol! fo the client's treatment plan. Rationale: Haloperidol may reduce hallucinations. Radiation therapy helps prevent cellular growth. It may be used to cure the cancer or to control malignancy when the tumor cannot be removed or when lymph node involvement is present, and it can be used prophylactically to prevent spread. Biopsy is used to analyze the lymph nodes or to destroy the tissues surrounding the tumor.  Which "awareness context" is characterized by the client, family, and health care professionals understanding that the client is dying, but all pretend otherwise? Closed awareness Suspected awareness Open awareness @ Mutual pretense awareness Correct Response: Mutual pretense awareness Rationale: In mutual pretense awareness, the client, the family, and the health care professionals are aware that the client is dying, but all pretend otherwise. In closed awareness, the client is unaware of his or her terminal state, whereas others are aware. In suspected awareness, the client suspects what others know and attempts to find it out. In open awareness, all are aware that the client is dying and are able to acknowledge that reality openly. According to federal guidelines, hospices may provide no more than what percentage of the aggregate annual patient-days at the inpatient level? @ 20 10 40 30 Correct Response: 20 Rationale: According to federal guidelines, hospices may provide no more than 20% of the aggregate annual patient-days at the inpatient level. The other numerical values are incorrect.  Which is the initial stage of grief, according to Kubler-Ross? Bargaining 8 Denial Anger Depression Correct Response: Denial Rationale: The stages of grief include denial, anger, bargaining, depression, and acceptance. Anger is the second stage of the process. Bargaining is the third stage of the process. Depression is the fourth stage of the process.  The family members of a dying client are finding it difficult to verbalize their feelings for and show tenderness to the client. Which nursing interventions should a nurse perform in such a situation? Be a silent observer and allow the client to communicate with the family members. @ Encourage the family members to express their feelings and listen to them in their frank communication. Encourage conversations about the impending death of the client. Encourage the client's family members to spend time with the client. Correct Response: Encourage the family members to express their feelings and listen to them in their frank communication. Rationale: Family members usually find it difficult to communicate frankly with a dying person. By encouraging family members to express their feelings and listening to them as they frankly communicate, you may help family members feel more prepared to carry on a similarly honest dialogue with the dying client. It is not advisable for the nurse to encourage conversations about the impending death of the client. Being a silent observer or encouraging the family members to spend time with the dying client may not help the family members to express their feelings.  Which intervention should a nurse perform during the grieving period when caring for a dying client? Providing palliative care Allowing a period of privacy @ Avoiding criticizing or giving advice Spending time with client Correct Response: Avoiding criticizing or giving advice Rationale: The nurse should listen in a nonjudgmental manner and should avoid criticizing or giving advice during the grieving period when caring for dying clients. Allowing a period of privacy is necessary to help family members cope with the death of a client and is not necessary during the grieving period. Spending time with the client and providing palliative care are not required nursing interventions during the grieving period. Palliative care is provided to a dying client when the client is unable to live independently. Which is a sign of approaching death? Insomnia @ Irregular breathing patterns Increase in urinary output Clear sensorium Correct Response: Irregular breathing patterns Rationale: Irregular breathing patterns are a sign of impending death. Other signs of approaching death include decreased urinary output, mental confusion, and sleeping for longer periods of time.  A type of comprehensive care for clients whose disease is not responsive to cure is a terminal illness. euthanasia. © palliative care. interdisciplinary collaboration. Correct Response: palliative care Rationale: Palliative care is a type of comprehensive care for clients whose disease is not responsive to cure. Terminal illness is a progressive, irreversible illness that despite cure-focused medical treatment will result in the client's death. Euthanasia means the intentional killing by act or omission of a dependent human being for his or her alleged benefit. Interdisciplinary collaboration is communication and cooperation among members of diverse health care disciplines jointly to plan, implement, and evaluate care.  The client is 45 years old and has a family history of breast cancer. The client was diagnosed with breast cancer 2 months ago. During a routine visit, the physician prescribes dexamethasone to be taken over a 3-week period. Which symptom would prompt the physician to add dexamethasone to the client's treatment plan? Massive swelling in the arm Coarse skin around the breast @ An B-lb (3.6-kg) weight loss Frequent bloody discharge from the breast Correct Response: An 8-Ib (3.6-kg) weight loss Rationale: Dexamethasone initially increases appetite and may provide short-term weight gain in some clients. Massive swelling in the arm is indicative of edema, which occurs due to advanced nodal involvement. Radiation therapy with ionizing radiation stops cellular growth. This therapy may be used to cure the cancer or to control malignancy when the tumor cannot be removed or when lymph node involvement is present, and it can be used prophylactically to prevent spread. Other symptoms of breast cancer may include scaly skin around the nipple, skin changes, erythema, and clear, milky, or bloody discharge. These symptoms, however, will not prompt the physician to prescribe dexamethasone therapy.  Which action by the nurse demonstrates an effective method to assess the client and the client's family's ability to cope with end-of-life interventions? Providing evidenced-based advice for end-of-life care based on the nurse's experiences with previous clients in hospice Filling voids in conversation with information related to death and dying to avoid awkward moments during the admission interview Offering reassurance that the nurse has had 5 years of assisting clients in hospice and their families care for loved ones at the end of life @ Remaining silent, allowing the client and family to respond after asking a question related to end-of-life care Correct Response: Remaining silent, allowing the client and family to respond after asking a question related to end-of-life care Rationale: Akey to effective listening includes allowing the client and family sufficient time to reflect and respond after asking a question. Hospice nurses with effective listening skills resist the impulse to fill the empty space in communication with talk, avoid the impulse to give advice, and avoid responses indicating, "| know just how you feel.”  Medicare and Medicaid hospice benefit criteria allow clients with a life expectancy of 6 months or less to be admitted to hospice. However, the median length of stay in a hospice program is just 21.3 days. Which reason explains the underuse of hospice care services? Qe Clients and families view hospice care as giving up Lack of Medicare/Medicaid funding for hospice Lack of fully credentialed and trained hospice nurses Difficulty obtaining Medicare certification for hospice services Correct Response: Clients and families view hospice care as giving up Rationale: Clients often equate hospice with giving up and are reluctant to accept hospice care. Lack of fully credentialed and trained hospice nurses is not a barrier to hospice care. Lack of Medicare funding and lack of certification for hospice service providers have not been documented as barriers to access of hospice services.  Aclient diagnosed with a terminal illness appoints her oldest son as the authorized individual to make medical decisions on her behalf when she is no longer able to speak for herself. Which proxy directive is the patient using? Medical directive by proxy End-of-life treatment directive Living will declaration Qo Durable power of attorney for health care Correct Response: Durable power of attorney for health care Rationale: A durable power of attorney for health care is also known as a health care power of attorney or a proxy directive. It allows another individual to make medical decisions on the client's behalf. The other options are incorrect. Which intervention should a nurse perform during the grieving period when caring for a dying client? Spending time with the client Providing palliative care Allowing a period of privacy @ Avoiding criticizing or giving advice Correct Response: Avoiding criticizing or giving advice Rationale: The nurse should listen in a nonjudgmental manner and should avoid criticizing or giving advice during the grieving period when caring for dying clients. Allowing a period of privacy is necessary to help family members cope with the death of a client and is not necessary during the grieving period. Spending time with the client and providing palliative care are not the required nursing interventions during the grieving period. Palliative care is provided to a dying client when the client is unable to live independently.  What barrier to end-of-life care does a dying client demonstrate with the statement, "I don't need hospice. Hospice is for people who are dying.” Bargaining Acceptance © Denial Anger Correct Response: Denial Rationale: Patient denial about the seriousness of terminal illness has been cited as a barrier to discussions about end-of-life treatment options. Denial includes feelings of isolation. Bargaining occurs when a client and/or family pleads for more time to reach an important goal. Anger includes feelings of rage or resentment. Acceptance occurs when the client and/or family are neither angry nor depressed. Which term refers to the period of time during which mourning of a loss takes place? Mourning © Bereavement Hospice Grief Correct Response: Bereavement Rationale: Bereavement is the period of time during which mourning of a loss takes place. Grief is defined as the personal feelings that accompany an anticipated or actual loss. Mourning is defined as the individual, family, group, and cultural expressions of grief and associated behaviors. Hospice is a coordinated program of interdisciplinary care and services provided primarily in the home to terminally ill clients and their families.  For individuals known to be dying by virtue of age and/or diagnosis, which sign indicates approaching death? Increased eating Increased wakefulness Increased urinary output @ Increased restlessness Correct Response: Increased restlessness Rationale: As the oxygen supply to the brain decreases, the patient may become restless. As the body weakens, the client will sleep more and begin to detach from the environment. For many clients, refusal of food is an indication that they are ready to die. Based on decreased intake, urinary output generally decreases in amount and frequency. Ch 19 Which is a potential complication of a low pressure in the endotracheal tube cuff? @ Aspiration pneumonia Pressure necrosis Tracheal ischemia Tracheal bleeding Correct Response: Aspiration pneumonia Rationale: Low pressure in the cuff can increase the risk for aspiration pneumonia. High pressure in the cuff can cause tracheal bleeding, ischemia, and pressure necrosis.