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 healthcare provider is mandated to perform a examination of the client and confirm death before any announcements to the family.
A. The DNR order indicates that the client has chosen not to receive CPR, so beginning resuscitation would go against their wishes.
B. Postmortem care is typically performed after the healthcare provider has pronounced the death
C. notifying the family is usually done after the healthcare provider has been informed and death has been confirmed.

A. When the client voided following catheter removal. B. Intake and output reports for the previous shift. C. Color of the urine during the catheter removal. D. Time of the last dose of IV antibiotic administration.

Correct Answer is A

Explanation

A. It is crucial to assess whether the client has been able to void successfully after catheter removal. The ability to void indicates that the urinary system is functioning properly and that there are no immediate complications such as urinary retention. If the client has not voided within an appropriate timeframe after catheter removal, further assessment and intervention may be necessary to prevent urinary retention or other urinary complications.

B. Understanding the client's fluid balance is essential, especially after catheter removal. However, it does not provide significant information on the client’s ability to void.
C. While the color of urine can provide insights into hydration and potential issues like hematuria, it's not as immediately critical as knowing if the client has successfully voided after catheter removal.
D. This information is relevant for monitoring antibiotic therapy but may not be as urgent as understanding the client's urinary status after catheter removal.

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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?

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Naxlex Comprehensive Predictor Exams

An older adult client with heart failure has a signed do not resuscitate (DNR) form to put in the medical record. The unlicensed assistive personnel (UAP) reports that the client is not breathing, and the nurse confirms the UAP's findings. Which action should the nurse take next?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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