A client receiving care on a palliative care unit is unable to swallow and is becoming dehydrated, which is exhibited by inelastic skin turgor and dry mucous membranes. Which action should the practical nurse (PN) implement to provide comfort?

Apply warm cloths to the skin.

Administer an as needed (PRN) analgesic.

Provide oral care frequently.

Elevate the extremities.

Answer and Explanation

The Correct Answer is C

A. Apply warm cloths to the skin: Warm cloths may provide general comfort, but they do not address dehydration-related discomfort or dryness of mucous membranes.

B. Administer an as needed (PRN) analgesic: Analgesics relieve pain, but dehydration primarily causes dryness and discomfort rather than pain, so this does not directly improve comfort in this scenario.

C. Provide oral care frequently: Frequent oral care, including moistening the mouth and lips, alleviates discomfort from dry mucous membranes, improves comfort, and helps maintain oral hygiene when the client is unable to swallow.

D. Elevate the extremities: Elevating extremities is used for edema or circulation issues and does not address dehydration or the associated oral discomfort.

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Correct Answer is A

Explanation

A. What are the voices uttering?: Determining the content of the hallucinations is most important because it helps assess whether the client is at risk of harm to self or others. If the voices are commanding or threatening, immediate safety interventions are required.

B. Which medication works best?: Although medication history is relevant for long-term management, it is secondary to assessing the current safety risk posed by the hallucinations.

C. When are the voices most disturbing?: This question helps identify triggers and patterns but is not the top priority during initial assessment when safety concerns must be addressed first.

D. How does the client cope with the voices?: Exploring coping mechanisms is important for ongoing care, but the primary concern upon admission is determining the nature of the hallucinations to ensure safety.

A. Tell the UAP to take the client back to his room. B. Provide client an assistive device, such as a cane or walker. C. Take over the ambulation and counsel the UAP later. D. Instruct the UAP to walk on the client's affected side.

Correct Answer is D

Explanation

A. Tell the UAP to take the client back to his room: Simply having the client return to the room does not correct the unsafe ambulation technique. Immediate guidance on proper positioning is more effective for preventing falls and injuries.

B. Provide client an assistive device, such as a cane or walker: While assistive devices can improve stability, proper ambulation technique and caregiver positioning are essential first steps to ensure safety during ambulation.

C. Take over the ambulation and counsel the UAP later: Taking over may prevent immediate harm, but it misses the opportunity to educate the UAP on proper technique, which is critical for ongoing client safety.

D. Instruct the UAP to walk on the client's affected side: The caregiver should walk on the client’s weak (affected) side to provide support, assist with balance, and prevent falls. Correct positioning during ambulation is the priority intervention to maintain safety.

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A client receiving care on a palliative care unit is unable to swallow and is becoming dehydrated, which is exhibited by inelastic skin turgor and dry mucous membranes. Which action should the practical nurse (PN) implement to provide comfort?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. What question is most important for the practical nurse (PN) to include in the assessment of this client?

Correct Answer is A

Explanation

The practical nurses (PN) notes that an unlicensed assistive personnel (UAP) is ambulating a male client who had a stroke and has right-sided weakness. The UAP is walking on the client's left side. Which action should the PN take?

Correct Answer is D

Explanation

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