The hospice nurse is teaching the family of a client receiving palliative care at home how to provide care. Which instruction should the nurse provide?
Report any change in urine color.
Maintain in high Fowler's position.
Keep mucous membranes moist.
Record the client's daily weights.
The Correct Answer is C
Choice A reason: Reporting any change in urine color is important but not specific to the provision of palliative care at home.
Choice B reason: Maintaining in high Fowler's position is not always necessary and may not be comfortable for all clients, especially in a palliative care setting.
Choice C reason: Keeping mucous membranes moist helps prevent discomfort and is a key part of providing compassionate end-of-life care.
Choice D reason: Recording the client's daily weights is less relevant in palliative care, where the focus is on comfort rather than ongoing medical assessments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A thick, dry, and dark area on bilateral heels may indicate the beginning stages of a pressure ulcer, but it is not the earliest sign. The earliest indication is usually a non-blanchable redness over a bony prominence.
Choice B reason: Broken skin without evidence of undermining could be a sign of a pressure ulcer, but it is not the earliest indication. The earliest sign is persistent redness over an area of pressure.
Choice C reason: A defined area of persistent redness over bone, especially if it does not blanch when pressed, is the earliest indication of a pressure ulcer. This stage is known as a Stage 1 pressure injury.
Choice D reason: A superficial sacral ulcer with defined margins indicates that a pressure ulcer has already developed and is not the earliest sign of its development.
Correct Answer is B
Explanation
Choice A reason: Glaucoma is not directly related to the administration of lidocaine, as it does not affect intraocular pressure or the pathophysiology of glaucoma.
Choice B reason: Heart block is a type of arrhythmia where the electrical signal is delayed or blocked entirely. Since lidocaine affects cardiac conduction, it is crucial to review the medical record for heart block before administration.
Choice C reason: Gastric ulcers are not typically a concern when administering lidocaine, as it does not have gastrointestinal effects when given parenterally.
Choice D reason: Diabetes mellitus is not a contraindication for lidocaine administration; however, monitoring blood glucose levels is always important in diabetic patients receiving any medication.
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