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.
Speak in a loud tone when addressing the client.
Offer the client a blanket to keep warm.
The Correct Answer is D
Rationale:
A. Place the client in a supine position: The supine position may impair respiratory function and increase discomfort, especially in terminal clients who may experience dyspnea. A semi-Fowler’s or side-lying position is often preferred for comfort and easier breathing.
B. Remind the client to eat scheduled meals daily: For clients nearing end of life, appetite naturally decreases, and forcing meals can cause distress. Care should focus on comfort, allowing the client to eat only if and when they desire rather than adhering to structured meal times.
C. Speak in a loud tone when addressing the client: Loud speech is not appropriate unless the client has documented hearing impairment. A calm, soft tone is more comforting and respectful, especially in the emotionally sensitive context of end-of-life care.
D. Offer the client a blanket to keep warm: Clients nearing the end of life often experience poor circulation and may feel cold. Providing a blanket is a comfort-focused, non-invasive intervention that promotes warmth and dignity during this phase.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D,A,B,C
Explanation
Rationale:
A. Insert the catheter until resistance is felt: The catheter should be gently advanced into the tracheostomy tube until resistance is met, which typically indicates reaching the carina.
B. Withdraw the catheter 1 to 2 cm (0.4 to 0.8 inch): Slight withdrawal prevents trauma to the carina and positions the catheter optimally for effective suctioning.
C. Rotate the catheter while suctioning: Rotating the catheter as suction is applied allows for even clearing of secretions along the tracheal walls and helps prevent localized tissue damage.
D. Lubricate the catheter with sterile saline: Lubrication ensures smooth insertion and reduces trauma to the tracheal mucosa. This is the first action after applying sterile gloves.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
Rationale for Correct Choices:
- Pain level: The client reports severe epigastric pain radiating to the back with a pain score increasing from 7 to 9 out of 10. Managing this acute pain is critical to improve the client's comfort, reduce stress response, and help prevent complications such as respiratory distress caused by shallow breathing due to pain.
- Blood pressure: The client’s blood pressure has dropped to 86/48 mm Hg, indicating hypotension that can lead to poor tissue perfusion and shock. After addressing pain, stabilizing blood pressure is essential to prevent organ dysfunction and maintain hemodynamic stability.
Rationale for Incorrect Choices:
- Lung sounds: Although diminished breath sounds and rhonchi are concerning and may indicate complications, immediate pain control can improve respiratory effort and oxygenation before focusing on lung sounds.
- Bowel sounds: Hypoactive bowel sounds are common in pancreatitis but are less urgent than pain and hypotension in acute care.
- Temperature: Fever suggests infection or inflammation but is a lower priority compared to controlling pain and stabilizing blood pressure.
- Blood glucose level: Elevated glucose requires monitoring but is less urgent than the client’s pain and hypotension in the acute phase.
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