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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Correct Answer is D

Explanation

D. The Situation, Background, Assessment, and Recommendation (SBAR) format of communication is commonly used in healthcare settings to facilitate effective and concise communication, especially when reporting critical information.
A. While effective communication is essential during discharge teaching to ensure that the client and family members understand the instructions and follow-up care, the SBAR format is not typically used in this context.
B. When offering therapeutic support and comfort to a grieving family, the focus is on empathy, active listening, and providing emotional support.
C. When obtaining clarification from a client's healthcare power-of-attorney, it's important to ensure that information is communicated accurately and any questions or concerns are addressed.

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 D

Explanation

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