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 A

Explanation

A. Hand hygiene, including washing hands before and after handling needles and syringes, is a fundamental component of standard precautions. It helps reduce the risk of transmitting pathogens between the client and the healthcare provider.
B. While wearing gloves is important for protecting oneself from potential exposure to bloodborne pathogens, it is part of personal protective equipment (PPE) precautions rather than standard precautions. Standard precautions primarily focus on hand hygiene and barrier precautions such as gloves, gowns, and masks when appropriate.
C. Wearing a face mask is not typically necessary for routine administration of medications, unless there is a risk of splashes or sprays of blood or body fluids. While it's important to protect mucous membranes from exposure to potentially infectious materials, the routine use of a face mask for medication administration is not a component of standard precautions.
D. This action is unsafe and does not demonstrate an understanding of standard precautions. Removing the needle before discarding the syringe increases the risk of needlestick injuries. Proper needle disposal involves keeping the needle intact with the syringe and disposing of them together in a puncture- resistant container.

A. Provide client focused information. B. Ask the client for learning feedback. C. Reinforce key points with the client. D. Observe the client's body language.

Correct Answer is B

Explanation

B. Asking the client for learning feedback ensures active participation in the learning process and allows the nurse to assess the client's understanding and retention of the information. It provides an opportunity for the client to ask questions, seek clarification, and express any concerns or uncertainties about the newly prescribed medication.
A. Client-focused information ensures that the education provided is relevant and meaningful to the individual, increasing the likelihood of comprehension and retention. However, learning feedback is more important.
C. Reinforcing key points ensures that important information is emphasized and repeated throughout the educational session. In this context however, learning feedback is crucial

D. Observing the client's body language is a nonverbal cue that can provide valuable insight into their level of engagement, understanding, and comfort with the educational material. Learning feedback, however, is more crucial.

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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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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?