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.
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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Related Questions
Correct Answer is D
Explanation
D. Using everyday language when explaining health-related issues is crucial when teaching older adult clients. Many older adults may have limited health literacy or cognitive impairments, so using complex medical terminology or jargon can lead to confusion and misunderstandings. By using simple, everyday language, the nurse can ensure that the information is easily understood and retained by the older adult clients.
A. Older adult clients may have visual impairments or difficulties with low lighting, so providing a well-lit meeting space is important for optimal visibility and comprehension. However, use of everyday language is more important.
B. Underlining key words on written materials can help older adult clients focus on important information and improve comprehension. However, use of everyday language is more important.
C. While it's important for the nurse to speak clearly and audibly, speaking loudly may not be necessary or appropriate, as it can be perceived as patronizing or intimidating.
Correct Answer is C
Explanation
C. This instruction ensures proper administration technique and minimizes the risk of injury or discomfort at the injection site. Injecting in the abdominal area provides a large and accessible SUBQ site for medication absorption. The distance of at least 2 inches (5.1 cm) from the umbilicus helps avoid injection into the umbilical region, reducing the risk of irritation or injury to the umbilicus.
A. Massaging the injection site is not recommended as it may cause the medication to disperse too quickly.
B. Rotating between the abdomen and gluteal areas is unnecessary for subcutaneous injections of this type.
D. It is also not required to expel the air from the prefilled syringe, as the air bubble can help ensure all the medication is administered.
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