A nurse is reinforcing preoperative teaching with a client who is to undergo a bowel resection at 1300 next week. Which of the following statements client indicates to the nurse a need for further teaching?

A. Moist mucous membranes: Moist mucous membranes are typically a sign of good hydration and are not usually associated with end-of-life stages. In fact, patients nearing the end of life often experience dryness of the mouth and mucous membranes due to decreased fluid intake and certain medications. This dryness can lead to discomfort and difficulties in swallowing or speaking, which is why oral care is an important part of end-of-life care.

B. Irregular respirations: This is correct. As the body’s systems start to shut down in the final stages of life, irregular respirations, including periods of rapid breathing and pauses (Cheyne-Stokes respirations), can be a common symptom. This happens because the body can no longer effectively remove carbon dioxide, and the automatic process of breathing becomes less coordinated. This can be distressing to witness, but it’s usually not uncomfortable for the patient.

C. Tachycardia: While some patients may experience changes in heart rate, tachycardia is not typically a consistent finding in patients at the end of life. As the body weakens, the heart has to work harder to pump blood, which can sometimes lead to a faster heart rate. However, as the end of life approaches, the heart rate often slows down, and blood pressure decreases.

D. Hypertension: Hypertension, or high blood pressure, is not typically a symptom associated with end-of-life care. In the final stages of life, the body’s systems begin to slow down, and blood pressure often decreases. This is due to a combination of factors, including a slower heart rate and a decrease in the body’s ability to regulate blood pressure. It’s also worth noting that pain, anxiety, and certain medications can temporarily increase blood pressure, even in the end-of-life stages.

A. Obtain the client’s consent: It is not the nurse’s responsibility to obtain the client’s consent for a procedure. This responsibility lies with the healthcare provider performing the procedure.

B. Describe the consequences of forgoing treatment: While it’s important for the client to understand the consequences of not undergoing the procedure, it is the healthcare provider’s responsibility to explain these consequences, not the nurses.

C. Witness the client’s signature: This is correct. The nurse’s role in the informed consent process is to witness the client’s signature on the consent form and to verify that the client is consenting voluntarily and appears to be competent to do so.

D. Explain the risks and benefits of the procedure: While the nurse can reinforce information, it is the healthcare provider’s responsibility to explain the risks and benefits of the procedure. The nurse should ensure that the client understands the information provided by the healthcare provider