A nurse is planning care for a client who has terminal cancer and is nearing the end of life. Which of the following interventions should the nurse include?
Place the client in a supine position.
Remind the client to eat scheduled meals daily.
Speak in a loud tone when addressing the client.
Offer the client a blanket to keep warm.
The Correct Answer is D
Rationale:
A. Place the client in a supine position: The supine position may impair respiratory function and increase discomfort, especially in terminal clients who may experience dyspnea. A semi-Fowler’s or side-lying position is often preferred for comfort and easier breathing.
B. Remind the client to eat scheduled meals daily: For clients nearing end of life, appetite naturally decreases, and forcing meals can cause distress. Care should focus on comfort, allowing the client to eat only if and when they desire rather than adhering to structured meal times.
C. Speak in a loud tone when addressing the client: Loud speech is not appropriate unless the client has documented hearing impairment. A calm, soft tone is more comforting and respectful, especially in the emotionally sensitive context of end-of-life care.
D. Offer the client a blanket to keep warm: Clients nearing the end of life often experience poor circulation and may feel cold. Providing a blanket is a comfort-focused, non-invasive intervention that promotes warmth and dignity during this phase.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Oxytocin: Oxytocin is the first-line uterotonic used to manage postpartum hemorrhage by stimulating uterine contractions to reduce bleeding. It is safe for use in clients with preeclampsia and does not elevate blood pressure.
B. Methylergonovine: Methylergonovine is contraindicated in clients with preeclampsia or hypertension because it causes vasoconstriction, which can dangerously elevate blood pressure and increase the risk of stroke or seizure.
C. Carboprost: Although carboprost is effective for postpartum hemorrhage, it should be used cautiously in clients with hypertension. It can cause bronchospasm and elevate blood pressure, which may worsen preeclampsia symptoms.
D. Nifedipine: Nifedipine is a calcium channel blocker used for managing hypertension and preterm labor. It is not indicated for treating postpartum hemorrhage as it lacks uterotonic effects.
Correct Answer is C
Explanation
Rationale:
A. Tomato allergy: A tomato allergy is not relevant to the ingredients used in total parenteral nutrition (TPN) with fat emulsion. Tomatoes are not a component of lipid emulsions, so this does not present a concern in this context.
B. Citrus allergy: Citrus fruits are also not involved in the formulation of fat emulsions or TPN components. Therefore, a citrus allergy would not require special precautions related to the prescribed therapy.
C. Egg allergy: Lipid emulsions used in TPN often contain egg phospholipids as an emulsifying agent. Clients with an egg allergy may experience a hypersensitivity reaction, making this a critical finding that must be reported to the provider immediately.
D. Wheat allergy: Wheat is not a component of standard TPN or fat emulsions. While wheat allergies are significant for dietary intake, they do not pose a known risk with parenteral nutrition administration.
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