A hospice nurse is planning care for a client who is near death. Which of the following actions should the nurse include in the client's plan of care to promote the client's comfort?
Elevate the head of the client's bed.
Offer the client ice chips.
Turn the client every 4 hours.
Provide oral care to the client every 6 hours.
The Correct Answer is A
Choice A reason: Elevating the head of the bed can help ease breathing and promote comfort for a client who is near death. This position can reduce the work of breathing and help prevent aspiration, which is crucial for clients with diminished consciousness or swallowing reflexes.
Choice B reason: Offering ice chips may provide some moisture and comfort to the client, but it is not the primary action to promote comfort for a client who is near death. Ice chips should be used cautiously, especially if the client has difficulty swallowing or is unconscious.
Choice C reason: Turning the client every 4 hours is important to prevent pressure ulcers and promote circulation. However, for a client who is near death, repositioning should be done with consideration for the client's comfort and any pain they may be experiencing.
Choice D reason: Providing oral care every 6 hours can help maintain oral hygiene and comfort, especially if the client is unable to perform this task themselves. It can also help prevent infections and manage any discomfort from dryness or buildup in the mouth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The child has recent onset of urinary incontinence is a possible sign of maltreatment, as it may indicate sexual abuse, emotional trauma, or neglect. The school nurse should report this finding to the child protective services and follow up with the child and the family¹².
Choice B reason: The child receives free lunches at school is not a sign of maltreatment, but rather a socioeconomic indicator. The school nurse should not assume that the child is maltreated based on this factor alone, but rather assess the child for other signs and symptoms of abuse or neglect³.
Choice C reason: The child has bruises on both knees is not a sign of maltreatment, but rather a common injury among children who are active and playful. The school nurse should not report this finding unless there are other suspicious circumstances, such as inconsistent explanations, unusual locations, or patterns of bruises⁴.
Choice D reason: The child reports having a toothache is not a sign of maltreatment, but rather a health issue that may require dental care. The school nurse should not report this finding unless there are other signs of neglect, such as poor oral hygiene, lack of access to health care, or failure to follow up on referrals⁵.
Correct Answer is B
Explanation
Choice A reason: Assessing the bladder for distention is an important action, but not the first one. The nurse should first check the uterine tone and position, as a boggy or displaced uterus can indicate uterine atony, the most common cause of postpartum hemorrhage.
Choice B reason: Massaging the client's fundus is the first action to take. The nurse should apply firm, circular pressure to the fundus to stimulate uterine contractions and reduce bleeding. The nurse should also monitor the amount and character of lochia.
Choice C reason: Preparing to administer a prescribed oxytocic preparation is a necessary action, but not the first one. The nurse should first attempt to control the bleeding by massaging the fundus and assessing the bladder. If the bleeding persists, the nurse should administer medications such as oxytocin, methylergonovine, or carboprost to enhance uterine contractions.
Choice D reason: Assessing the client's blood pressure is an important action, but not the first one. The nurse should first manage the bleeding by massaging the fundus and preparing to administer medications. The nurse should also monitor the client's vital signs, including blood pressure, pulse, and temperature, for signs of shock or infection
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