A nurse is caring for a client who is terminally ill. Which of the following findings should the nurse identify as an indication that palliative care should be recommended?

Constipation

Serum albumin 5.2 g/dL (3.5 to 5 g/dL)

Apnea alternating with hyperventilation

Peripheral edema

Answer and Explanation

The Correct Answer is C

A. Constipation: While constipation is a common symptom in terminally ill clients, it is a manageable condition that does not necessarily indicate the need for palliative care. It can be addressed with medication and lifestyle adjustments.

B. Serum albumin 5.2 g/dL (3.5 to 5 g/dL): This is within normal range and does not suggest a need for palliative care. Normal albumin levels indicate adequate nutritional status and liver function, so there is no immediate indication for palliative care based on this finding.

C. Apnea alternating with hyperventilation: Apnea alternating with hyperventilation is a sign of impending respiratory failure, which can be a symptom of terminal illness and often occurs in the final stages of life. This indicates that the client may benefit from palliative care to address comfort and end-of-life needs.

D. Peripheral edema: Peripheral edema can occur due to causes such as heart failure or kidney dysfunction. While it can be distressing, it does not necessarily indicate that palliative care is required. It can be treated with medical interventions and does not imply end-of-life.

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Correct Answer is A

Explanation

A. Place a mask on the client during the procedure: A mask should be placed on the client to reduce the risk of infection during the dressing change. Peritoneal dialysis involves accessing the peritoneal cavity, and maintaining a sterile environment is crucial to prevent contamination.

B. Cleanse the catheter site using a side-to-side motion: The catheter site should be cleansed using a circular motion starting from the site of insertion and moving outward. This helps avoid introducing bacteria into the insertion site. Side-to-side motion may push bacteria into the area.

C. Tape down the corners of the dressing: While securing the dressing is important, taping the corners may not provide the optimal seal and could risk introducing contaminants. The dressing should be secured properly, but not necessarily with just tape at the corners.

D. Secure an occlusive dressing over the gauze pads: An occlusive dressing over gauze pads is not ideal for peritoneal dialysis catheters. A sterile, breathable dressing is recommended to allow for proper airflow and prevent moisture accumulation, which can promote infection.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}

Explanation

Rationale for Correct Choices

Blood glucose: A blood glucose level of 250 mg/dL is critically elevated and puts the client at risk for complications such as delayed wound healing, infection, dehydration, and diabetic ketoacidosis (DKA) if unmanaged. Hyperglycemia impairs immune function and must be addressed promptly to stabilize the client's condition and support healing.
Wound : The draining, non-healing foot ulcer with purulent discharge indicates infection. However, uncontrolled glucose is a major contributing factor to poor wound healing and increased infection risk. Once glucose levels are addressed, wound care becomes the next critical focus to prevent systemic infection and further tissue damage.

Rationale for Incorrect Choices

Temperature: While the client has a low-grade fever (38.3°C), which may be related to the infected wound, treating the source of infection and controlling glucose will have a greater and more direct impact on resolving the fever.
Blood pressure: The blood pressure of 98/74 mm Hg is slightly low but not emergent and does not pose immediate risk. It can be monitored while more pressing concerns—like glucose and wound infection—are managed.
WBC count: The WBC count of 9,500/mm³ is within normal limits. Although it helps in evaluating infection, it does not require direct intervention and is not a clinical priority compared to glucose control and wound care.

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A nurse is caring for a client who is terminally ill. Which of the following findings should the nurse identify as an indication that palliative care should be recommended?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is changing the dressing for a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

Exhibits Complete the following sentence by using the lists of options. The nurse should first address the client's dropdownfollowed by the client'sdropdown.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}

Explanation

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