A nurse is reinforcing teaching about palliative care to a client who has cancer. Which of the following statements should the nurse make?

"It is for clients who have a terminal illness."

"It is for clients who are given 6 months or less to live."

"It includes restriction of nutritional support."

"It enhances quality of life by promoting comfort."

Answer and Explanation

The Correct Answer is D

A. Stating that palliative care is only for clients with a terminal illness is incorrect. Palliative care is designed for clients with serious, chronic, or life-threatening illnesses and focuses on symptom management and quality of life, regardless of prognosis.

B. Limiting palliative care to those with 6 months or less to live is incorrect. This definition applies to hospice care, not palliative care. Palliative care can be provided alongside curative treatments at any stage of illness.

C. Including restriction of nutritional support is incorrect. Palliative care emphasizes comfort and symptom relief, including providing adequate nutrition and hydration as appropriate for the client’s needs and wishes.

D. Enhancing quality of life by promoting comfort is correct. Palliative care aims to relieve symptoms such as pain, nausea, and fatigue while supporting the client’s emotional, psychological, and spiritual well-being.

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Correct Answer is C

Explanation

A. Platelet count is normal (175,000/mm3) and does not require reporting to the provider.

B. Sputum color: While thick green sputum might suggest infection, the nurse should first assess for other clinical signs, and it might not need immediate reporting unless there are other concerns, like a change in respiratory status.

C. Temperature (38°C / 100.4°F) is elevated, which could indicate an infection, such as a respiratory infection or exacerbation of COPD. This finding should be reported to the provider because fever in a client with COPD could lead to complications like pneumonia or exacerbation of symptoms.

D. Fluid intake of 2,200 mL/24 hr is within normal limits and does not need reporting.

A. Cover the wound with sterile, saline-soaked gauze. B. Hold gentle, direct pressure on the protruding organ. C. Place the client's knees in an extended position. D. Raise the head of the bed to a 45° angle.

Correct Answer is A

Explanation

A. Covering the wound with sterile, saline-soaked gauze is correct. Evisceration occurs when abdominal contents protrude through a surgical wound. To prevent drying and further tissue damage, the nurse should immediately cover the exposed organs with sterile gauze moistened with saline to maintain moisture and reduce infection risk.

B. Holding gentle, direct pressure on the protruding organ is incorrect. Applying pressure can cause further damage to the exposed tissue and increase the risk of complications. Instead, the focus should be on protecting the organs and minimizing contamination.

C. Placing the client’s knees in an extended position is incorrect. Keeping the knees straight can increase tension on the wound. Instead, the nurse should position the client with the knees slightly flexed to reduce strain on the abdominal incision.

D. Raising the head of the bed to a 45° angle is incorrect. A high Fowler’s position can increase pressure on the wound. The nurse should place the client in a low Fowler’s position (supine with knees slightly flexed. to reduce tension and prevent further protrusion.

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A nurse is reinforcing teaching about palliative care to a client who has cancer. Which of the following statements should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits A nurse is reviewing the medical record of a client who has COPD. Which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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