A nurse is planning care for a client who is to begin receiving hospice care. Which of the following interventions should the nurse include in the plan?

Insert a peripheral catheter to deliver intravenous fluids.

Obtain a prescription for parenteral nutrition.

Offer the client massage therapy:

Initiate a referral for physical therapy.

Answer and Explanation

The Correct Answer is C

A. Insert a peripheral catheter to deliver intravenous fluids: Routine IV fluid administration is not a standard intervention in hospice care unless specifically indicated for symptom management. The focus in hospice is on comfort and quality of life rather than aggressive interventions, so placing an IV line for routine hydration is generally avoided.

B. Obtain a prescription for parenteral nutrition: Parenteral nutrition is typically not initiated in hospice care because it does not improve comfort or quality of life and may cause discomfort or complications. Hospice care prioritizes symptom management, pain relief, and emotional support rather than aggressive nutritional interventions.

C. Offer the client massage therapy: Massage therapy is an appropriate intervention in hospice care as it promotes comfort, reduces pain, alleviates anxiety, and supports emotional well-being. Complementary therapies like massage are aligned with hospice goals of enhancing quality of life and providing holistic care for clients nearing the end of life.

D. Initiate a referral for physical therapy: Physical therapy in hospice is generally limited and focused only on maintaining comfort and safe mobility rather than improving function or strength. While referrals can be made if needed, massage therapy is a more direct intervention to address comfort and symptom management at this stage of care.

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Correct Answer is A

Explanation

A. Take this medication at the same time each day: Consistent timing helps maintain stable anticoagulation levels and reduces the risk of under- or over-anticoagulation. Warfarin’s effectiveness and safety depend on steady dosing and adherence to a regular schedule.

B. Take ginger for constipation while on this medication: Ginger can increase the risk of bleeding when taken with warfarin due to its antiplatelet properties. Clients should avoid supplements or herbal remedies that may interact with anticoagulants unless approved by the healthcare provider.

C. Eat foods high in vitamin K: Foods high in vitamin K, such as leafy greens, can decrease the effectiveness of warfarin by promoting clotting. Clients should maintain a consistent intake rather than increasing consumption to avoid fluctuations in anticoagulation levels.

D. Shave with disposable razors: Clients on warfarin are advised to use electric razors instead of disposable or manual razors to reduce the risk of cuts and bleeding. Using disposable razors increases the likelihood of minor injuries that can lead to excessive bleeding.

A. Protruding hemorrhoids B. 3+deep-tendon reflexes C. Supine hypotension D. Urinary frequency

Correct Answer is B

Explanation

A. Protruding hemorrhoids: Hemorrhoids are common in late pregnancy due to increased venous pressure and straining, and while uncomfortable, they are not an urgent concern requiring immediate provider notification.

B. 3+ deep-tendon reflexes: Hyperactive reflexes (3+) can indicate potential preeclampsia, which is a serious condition characterized by hypertension and risk of seizures. This finding requires prompt reporting and further evaluation to prevent complications for both the mother and fetus.

C. Supine hypotension: Supine hypotensive syndrome can occur when a pregnant client lies on her back, causing compression of the inferior vena cava. It is typically relieved by repositioning to the left lateral side and is not immediately dangerous if addressed promptly.

D. Urinary frequency: Increased urinary frequency is common in late pregnancy due to fetal pressure on the bladder. While it may cause discomfort, it is an expected finding and does not require urgent reporting to the provider.

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A nurse is planning care for a client who is to begin receiving hospice care. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

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