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 A

Explanation

The correct answer is choice A. Auscultate the client's abdomen for bowel sounds. This is the first action the nurse should take because it provides information about the client's bowel motility and function. Opioid medications can decrease bowel motility and cause constipation. The nurse should assess the client's abdomen before implementing any interventions.

Choice B is not correct because providing privacy and a set time to defecate is a nonpharmacological intervention that can help prevent constipation, but it is not the first action the nurse should take.
Choice C is not correct because administering a fiber-based laxative is a pharmacological intervention that can help treat constipation, but it is not the first action the nurse should take. The nurse should also consider the client's fluid intake and preference before giving a laxative.
Choice D is not correct because encouraging the client to increase oral intake of fluids is a nonpharmacological intervention that can help prevent constipation, but it is not the first action the nurse should take. The nurse should also consider the client's fluid balance and medical condition before giving fluids.

A. "I will wash my hands as soon as I leave the room." B. "I will wear a gown when I help my partner take a bath." C. "I can reuse unsoiled gloves when I re-enter the room." D. "I can take my partner outside of the room as long as they wear a mask."

Correct Answer is A

Explanation

The correct answer is choice A. Washing hands after leaving the room is an important infection control measure for individuals who come into contact with clients on contact precautions. Choice B is incorrect because gowns are only necessary when there is a risk of contact with the client's body fluids. Choice C is incorrect because gloves should not be reused. Choice D is incorrect because the client should not leave the room while on contact precautions. Choice B is not correct because gowns are only necessary when there is a risk of contact with the client's body fluids. Choice C is not correct because gloves should not be reused. Choice D is not correct because the client should not leave the room while on contact precautions.

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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

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Correct Answer is A

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