A nurse is planning care for a client who has terminal cancer and is nearing the end of life. Which of the following interventions should the nurse include?
Place the client in a supine position
Remind the client to eat scheduled meals daily.
Offer the client a blanket to keep warm.
Speak in a loud tone when addressing the client
The Correct Answer is C
A. Place the client in a supine position. As clients near the end of life, the supine position may compromise breathing. A semi-Fowler’s or lateral position is usually preferred to promote comfort and respiratory ease.
B. Remind the client to eat scheduled meals daily. At the end of life, appetite typically decreases, and forcing food can cause discomfort. Nutrition should be offered based on the client's desire, not forced on a strict schedule.
C. Offer the client a blanket to keep warm. Clients nearing death often experience peripheral circulation decline, leading to feelings of coldness. Providing a blanket promotes comfort and warmth without being invasive.
D. Speak in a loud tone when addressing the client. Loud speech can be disorienting and distressing, especially if the client is already weak or confused. Use a calm, clear, and gentle tone to provide comfort and maintain dignity.
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Correct Answer is D,A,B,C
Explanation
D. Transport the client to another area of the nursing unit. The first priority is rescue ensuring the client’s safety by removing them from the immediate area of danger, which is consistent with the "RACE" fire safety protocol (Rescue, Alarm, Contain, Extinguish).
A. Activate the facility's fire alarm system. Once the client is safe, the next step is to activate the fire alarm to notify other staff and initiate emergency protocols throughout the facility.
B. Close all nearby windows and doors. Containing the fire by closing doors and windows limits the spread of smoke and flames, buying time for response teams to arrive and control the situation.
C. Use the unit's fire extinguisher to attempt to put out the fire. If it is safe and the fire is small and manageable, the final step is to extinguish the fire using a fire extinguisher, following appropriate safety procedures.
Correct Answer is C
Explanation
A. Educating clients about contraindications to specific immunizations. This is an example of primary prevention, which aims to prevent disease before it occurs by promoting safe practices and avoiding harmful exposures.
B. Providing clients with information about the benefits of exercise. This also falls under primary prevention, as it promotes a healthy lifestyle to prevent the onset of disease or complications.
C. Using an electronic messaging system to remind clients when to take medications. This is an example of tertiary prevention, which focuses on managing chronic conditions (like HIV) and preventing complications or progression of the disease through adherence support.
D. Helping clients understand health screenings covered by their insurance plans. This is considered secondary prevention, which involves early detection and prompt intervention to catch diseases in the early stages through screenings.
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