A nurse is reinforcing teaching about end-of-life care with the partner of a client.Which of the following statements should the nurse make?

"Encourage your partner to eat three large meals each day.”.

"Opioids will be restricted if your partner develops respiratory distress.”.

"We will use an electric blanket to keep your partner warm.”.

"Assume your partner can hear you, even if they do not respond.”. .

Answer and Explanation

The Correct Answer is D

Choice A rationale

Encouraging a partner to eat three large meals each day may not be appropriate in end-of-life care. Clients often have reduced appetite, and small, frequent meals are usually recommended to avoid overwhelming them.

Choice B rationale

Opioids are commonly used in end-of-life care to manage pain and distress. Even if respiratory distress occurs, opioids are not typically restricted, but rather adjusted to balance pain relief and respiratory function.

Choice C rationale

Using an electric blanket can pose safety risks, including burns or electrical hazards, especially if the client is unable to communicate discomfort. Instead, alternative methods such as warm blankets are safer.

Choice D rationale

Assuming the partner can hear even if they do not respond is important. Hearing is believed to be one of the last senses to fade, and speaking to the client can provide comfort and connection.

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Correct Answer is A

Explanation

Choice A rationale

Flexing hips and knees when assisting the client to a standing position uses proper body mechanics, reducing the risk of injury to both the nurse and the client. It provides a stable base of support during the transfer.

Choice B rationale

Pivoting on the foot farthest from the bed when assisting the client into the chair is incorrect. The nurse should pivot on the foot closest to the bed to maintain balance and control during the transfer.

Choice C rationale

Standing on the client's stronger side when moving the client into the chair is incorrect. The nurse should stand on the client's weaker side to provide support and prevent falls.

Choice D rationale

Raising the bed to waist level before moving the client is incorrect as it may not provide the best ergonomic position for the transfer. The bed should be at a height that ensures the nurse’s safety and facilitates the client's movement.

A. Review the client's photograph in the medical record. B. Request an assistive personnel to identify the client. C. Ask the client to state their room number. D. Have the client state their phone number.

Correct Answer is A

Explanation

Choice A rationale

Reviewing the client's photograph in the medical record is an effective method to ensure accurate identification. This practice aligns with patient safety protocols and minimizes the risk of medication errors by confirming the patient's identity through a visual match with a documented image.

Choice B rationale

Requesting an assistive personnel to identify the client might be unreliable if the personnel is unfamiliar with the client or makes an error. This approach does not provide a secure verification method and could lead to mistakes.

Choice C rationale

Asking the client to state their room number is not reliable since a client with advanced dementia may not remember their room number accurately. This method does not ensure proper identification and can lead to errors.

Choice D rationale

Having the client state their phone number is inappropriate for clients with advanced dementia, who may struggle to recall such information. This method is not a secure or accurate way to verify identity.

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A nurse is reinforcing teaching about end-of-life care with the partner of a client.Which of the following statements should the nurse make?

Nursing Test Bank

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