The palliative care nurse receives a consult for a terminally ill client in the intensive care unit. The client is weak, mouth breathing. and refusing anything to eat or drink. Which intervention should the nurse include plan of care?

Keep mucous membranes moist.

Record the client's daily weight.

Maintain in high Fowler's position.

Report any change in urine color.

Answer and Explanation

The Correct Answer is A

A. Keeping the mucous membranes moist is essential for comfort and preventing discomfort associated with dryness, especially in a client who is weak and mouth breathing. This intervention can help prevent issues such as dry mouth, cracked lips, and irritation of the oral mucosa, which can contribute to discomfort and difficulty swallowing.
B.   Monitoring the client's weight can provide valuable information about fluid balance and nutritional status but in the context of a terminally ill client who is weak and refusing to eat or drink, daily weight monitoring may not be as relevant or informative.
C.   The high Fowler's position is often used to improve breathing comfort and lung expansion in clients experiencing respiratory distress. However, in a terminally ill client who is weak and mouth breathing, maintaining them in a high Fowler's position may not be necessary or comfortable.

D.   While monitoring urine output and characteristics is important for assessing renal function and hydration status, changes in urine color may not be a priority in the care of a terminally ill client who is weak and not consuming fluids.

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Free Nursing Study Resources

Correct Answer is B

Explanation

B. Using a PAP device helps maintain airway patency and prevents episodes of apnea or hypopnea, reducing the risk of respiratory complications associated with opioid analgesics.
A. While ensuring safety by raising side rails is important, it may not directly address the risk of respiratory depression associated with opioid analgesics or support airway patency.
C. Elevating the head of the bed can improve respiratory mechanics and reduce the risk of airway obstruction, but it may not be as effective as using a PAP device for a client with severe obstructive sleep apnea.
D. While removing dentures or oral appliances may be necessary for some clients to maintain airway patency, it may not be the most important intervention in this situation.

A. Allows 30 minutes of rest before feeding B. Places food on the unaffected side of the mouth. C. Raises the head of the bed to 60 degrees. D. Positions the head with the chin tilted slightly downward.

Correct Answer is C

No explanation

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The palliative care nurse receives a consult for a terminally ill client in the intensive care unit. The client is weak, mouth breathing. and refusing anything to eat or drink. Which intervention should the nurse include plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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