A nurse is caring for a client who has a terminal illness and is in the active phase of dying. The client refuses further hydration and nourishment. What action should the nurse take?
Ask the client's healthcare surrogate for permission to withhold nourishment.
Request a prescription for IV fluids.
Explain the importance of oral hydration to the client.
Provide regular oral care for the client with a moist swab.
The Correct Answer is D
The correct answer is choice D. Provide regular oral care for the client with a moist swab. When a client with a terminal illness and in the active phase of dying refuses further hydration and nourishment, the nurse should provide comfort measures such as regular oral care to prevent discomfort. The nurse should not force the client to eat or drink or request a prescription for IV fluids. The healthcare surrogate cannot be asked for permission to withhold nourishment as the client has the right to refuse nourishment.
Option A - The client has the right to refuse nourishment, and healthcare surrogate permission is not required.
Option B - Requesting a prescription for IV fluids is not an appropriate intervention as the client has the right to refuse nourishment.
Option C - Explaining the importance of oral hydration to the client is not an appropriate intervention as the client has the right to refuse nourishment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1000"]
Explanation
To calculate the number of calories the client should reduce their daily intake by to lose 0.9 kg (2 lb) of body fat per week , we can use the following formula: (0.9 kg/week) x (1 lb/0.45 kg) x (3500 calories/1 lb) = 7,000 calories/week To find the daily calorie reduction, divide 7,000 by 7 days: 7,000 calories/7 days = 1,000 calories/day Therefore, the nurse should instruct the client to reduce their daily caloric intake by 1,000 calories. Answer: 1000
Correct Answer is A
Explanation
The correct answer is: Choice A: Maintain direct pressure over the site.
Here's the rationale for each choice:
- Choice A: Maintain direct pressure over the site (CORRECT) This is the most important initial step in controlling bleeding for any patient, especially one with hemophilia who has a deficiency in clotting factors. Maintaining pressure directly on the wound helps to form a clot and stop the bleeding.
- Choice B: Check whether the bleeding has stopped While checking for bleeding cessation is important, it shouldn't be the immediate next step after applying a dressing. Maintaining pressure ensures the dressing remains effective. Once pressure is released, you can assess for continued bleeding.
- Choice C: Obtain a radial pulse Assessing the radial pulse is not directly related to managing the bleeding from the laceration. While it's a vital sign, it's not a priority in this situation.
- Choice D: Reinforce the dressing over the site While reinforcing the dressing might be necessary later if it becomes saturated with blood, maintaining direct pressure is the crucial first step.
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