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 C

Explanation

C. Given the client's diagnosis of type 2 diabetes mellitus and the development of hyperglycemia requiring insulin injections after discharge, the priority outcome is for the client to adhere to the medication regimen. Proper management of diabetes through consistent adherence to insulin therapy is crucial for controlling blood sugar levels and preventing complications. Therefore, ensuring the client's understanding of and commitment to the medication regimen is essential for achieving optimal health outcomes.
A. While important for the client's overall postoperative care, it does not directly address the management of hyperglycemia or the need for insulin injections.
B. This outcome statement pertains to respiratory assessment, which is important for monitoring postoperative recovery, particularly after surgery involving the abdomen. However, it does not specifically address the management of hyperglycemia or the need for insulin injections.
D. This outcome statement highlights the client's ability to perform a specific aspect of self-care related to insulin administration. However, it focuses on the client's initial attempts rather than the desired outcome of successfully administering insulin.

A. Massage the injection site to increase absorption. B. Rotate injections between the abdomen and gluteal areas. C. Inject in abdominal area at least 2 in (5.1 cm) from the umbilicus. D. Expel the air in the prefilled syringe prior to injection.

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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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

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Correct Answer is C

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