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Set 1: Question #1 of 6

84-year-old client diagnosed with stage 4 lung cancer with metastasis to the brain and liver. Client lives with his daughter and her family, who are his main caregivers at home. Client's advance directive states that he does not want CPR, intravenous fluids, antibiotics, a feeding tube, or hospitalization at the end of life. Daughter is his health care power of attorney.
Client sitting in recliner. Awake and confused, and insists he needs to go see his wife, who has been deceased for 15 years. Daughter states is very concerned because the client has become more agitated over the past two days and is not sleeping at night. Client's skin is hot and pale, oral mucosa dry. Breath sounds diminished throughout with coarse rhonchi on the right. Productive cough with large amounts of thick, white sputum. Client reports “terrible” pain in his back that is not being relieved by his current pain medication. Taking sips of water, but refuses food and reports having no appetite.
BP 108/60
HR 88 irregular
Temp 100.8°F (38.22°C)
RR 18
SpO2 92% on 2L O2/NC
Highlight the information which is most important for the nurse to consider when providing care for this client.
  • advance directive information
  • confused
  • more agitated
  • not sleeping
  • BP 108/60
  • SpO2 92% ON 2L O2/NC
  • temperature 100.8
  • breath sounds
  • productive cough
  • pain not relieved
  • sips of water
  • refusing food