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A nurse is caring for a client who in the end of life dying process. Current Data Vital Signs 1200 Temperature 34.7* C (94.5* F) Heart Rate 25/minute Respiratory rate irregular with Cheyne-Stokes respiration  Blood pressure 52/38 mmHg Nurses’ Notes 0800 Client does not arouse to verbal, tactile, or painful stimulation.  Heart rate 35/min, irregular.  Pulses to extremities nonpalpable, skin cool to touch with pallor and mottling.  Cheyne-stokes breathing, noisy respirations with copious secretions.  Indwelling urinary catheter in place, 10mL dark amber urine output.  Decreased muscle tone noted.  Client moaning.  Medicated with morphine 4mg IV bolus.  Client has a do-not-resuscitate order in place.  Family at bedside.  Update on client’s condition provided.  What sign/symptom indicates death is nearing?  Fill in blank one with using this Wordbank:  Moaning, StrongPulses, IncreasedUrine or CheyneStokes _______ Which of the following is a clinical confirmation of death? Fill in blank two using this Wordbank: ActiveReflexes, FlatBrainWaves, SlowBreathing or PainResponses _______

The LPN is collecting data on a client’s pressure injury and observes adipose tissue in the base of the wound. Based on this information, what stage of pressure injury should the nurse document?

The care plan states: Impaired Skin Integrity related to immobility as evidenced by reddened area of skin on the heels and back. Which part of this phrase represents the etiology of the nursing diagnosis/clinical problem?

How is practical nurse licensure and registration to practice earned? Note: You are now beginning the exam. Please show both sides of your whiteboard to the camera.

A nurse is providing care to a terminally ill client. Which findings are signs/symptoms of impending death? Select all that apply

The nurse is caring for a client with a post-op infection. The client’s current blood pressure is 82/58 and heart rate is 138. What type of IV fluids should the nurse expect to administer?

A 10 year old child visits the health care facility for a well child visit. What priority data will the LPN collect as part of the respiratory assessment? (Select all that apply.)

The LPN observes the client is blowing into the incentive spirometry device. What is the correct response from the nurse?

A client is experiencing respiratory distress. Which clinical problem is most likely on the client’s plan of care?

In providing nursing care, which of the following is mostly likely to improve holistic patient outcomes?