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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

The correct answer is choice C: Blood pressure change from 118/78 mm Hg to 86/50 mm Hg.

Choice C rationale: A significant drop in blood pressure can indicate various serious conditions, such as shock, hemorrhage, or a severe infection. The nurse should assess the client further and intervene as necessary to prevent complications.

Choice A rationale: The change in temperature may indicate the onset of a fever and requires further assessment, but it is not as immediately concerning as the sudden drop in blood pressure.

Choice B rationale: The change in respiratory rate could be a result of factors like pain, anxiety, or exercise. While it warrants further assessment, it is not as critical as the blood pressure change.

Choice D rationale: The heart rate change may be a response to medications, rest, or other factors. It should be monitored and assessed, but the priority finding is the blood pressure change, which may indicate a more severe underlying issue.

A. Orthopneic B. Trendelenburg C. Prone D. Knee-chest

Correct Answer is D

Explanation

knee-chest. During sigmoidoscopy, the client should lie on their left side with their right knee flexed slightly. The nurse should then position the client in the knee-chest (Sims) position, where the client leans forward with bent knees and support the chest and forearms on the table or a pillow. This allows better visualization and access to the rectal area for the sigmoidoscopy procedure.

An explanation for incorrect choices:

A. Orthopneic position is upright sitting with arms and elbows resting on a table or on a pillow, which helps clients who have difficulty breathing; it is not suitable for sigmoidoscopy.

B. Trendelenburg position

is supine with the head lower than the feet, which can cause blood flow to the head and increased intracranial pressure; it is not suitable for sigmoidoscopy.

C. Prone position is lying face down, which is not suitable for sigmoidoscopy.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing vital signs obtained by an assistive personnel on a group of clients. The previous vital signs for each of the clients were obtained 4 hours earlier. Which of the following changes should the nurse identify as the priority finding?

Correct Answer is C

Explanation

A nurse is preparing a client for a sigmoidoscopy. In which of the following positions should the nurse place the client?

Correct Answer is D

Explanation

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