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A nurse is caring for a client who is in the late stage of the dying process.

Exhibits

Which of the following interventions should the nurse perform for this client? Select all that apply.

Place client in supine position with foot of bed elevated.

Place ice chips in mouth as needed.

Apply lubricating [LW1] ophthalmic drops PRN.

Administer furosemide 40 mg orally.

Administer albuterol nebulizer treatments 10 mg every 1 to 4 hr PRN.

Swab mouth with moisturizer as needed.

Answer and Explanation

Correct Answer : B,C,F

A. Supine with foot of bed elevated
Can worsen respiratory effort in dying clients.

B. Place ice chips in mouth
Helps soothe dry mouth and maintain comfort.

C. Lubricating eye drops PRN
Maintains moisture and prevents eye irritation when blinking diminishes.

D. Administer furosemide
Not indicated in comfort care/DNR-focus is not on aggressive fluid removal.

E. Albuterol every 1–4 hr
Not typically part of end-of-life comfort care unless specifically needed for comfort.

F. Swab mouth with moisturizer
Prevents dryness, cracking-important for comfort in the dying process.

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Correct Answer is B

Explanation

A. "I feel more alert..."
Suggests mania or improved focus, not depression.

B. "I can't stop my mind racing at night..."
Reflects insomnia and anxiety, often associated with depression.

C. "I have high blood pressure."
A physical health issue; not indicative of depression.

D. "I can’t sit still..."
May suggest anxiety or mania, but not classic for depression.

A. Allow the client time alone to self-reflect. B. Encourage the client to focus on the positive aspects of life. C. Ask the client about the lethality of their plan. D. Reassure the client that everything is going to work out.

Correct Answer is C

Explanation

A. Allow the client time alone to self-reflect.
Leaving a suicidal client alone poses a risk of self-harm. Continuous monitoring is required.

B. Encourage the client to focus on the positive aspects of life.
While positivity is helpful later, this response minimizes the client’s suicidal ideation and fails to assess immediate risk.

C. Ask the client about the lethality of their plan.
This is essential for determining the level of suicide risk. Asking directly about suicidal intent, plan, and means is critical.

D. Reassure the client that everything is going to work out.
This is false reassurance, which can shut down communication and invalidate the client's distress.

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A nurse is caring for a client who is in the late stage of the dying process. Exhibits Which of the following interventions should the nurse perform for this client? Select all that apply.

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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A nurse is caring for a client who is in the late stage of the dying process.

Exhibits

Which of the following interventions should the nurse perform for this client? Select all that apply.