A terminal patient has a gurgling sound, sometimes called a "death rattle." Which nursing diagnosis should guide interventions?
a. Impaired Gas Exchange
b. Ineffective Airway Clearance
c. Impaired Oral Mucous Membranes
d. Ineffective Breathing Pattern
ANS: B
Saliva that the patient is now unable to swallow may collect in the back of the throat, causing a sound sometimes called a "death rattle." Impaired gas exchange would occur deeper in the lungs. Mucous membranes are not necessarily involved, and breathing pattern refers to breathing rhythm or rate, not airway patency.
You might also like to view...
Which recommendations for daily food intake is correct for older adults according to the Food Guide Pyramid for Older Adults from Tufts University?
a. Three 8-ounce glasses of water b. Two servings of deep-colored fruit c. Four or more servings of high-quality protein d. One or two servings of brightly colored vegetables e. Three or more servings of low-fat or nonfat dairy products f. Six or more servings of fortified, enriched, or whole grain foods
The nurse acts as an empowering agent in health promotion by:
a. coordinating all of a patient's health care. b. focusing on the patient's anxiety and fears related to change. c. including the patient in every aspect of care. d. motivating patient behavior through description of negative outcomes.
Why do older persons adapt more slowly to changes in the peripheral vascular system? (Select all that apply.)
a. Slowing heart rate b. Decreasing cardiac output c. Increasing stroke volume d. Stiffening of blood vessels e. Thickening of aorta
A nurse is admitting a patient, has completed the health history, and is now doing a physical assessment. The physical assessment will provide what type of data?
A) Concrete B) Subjective C) Realistic D) Objective