A nurse on a hospice unit is caring for a client who has cancer and is in the active phase of dying. Which of the following findings requires intervention by the nurse?

An assistive personnel is encouraging intake of oral fluids.

Supplemental oxygen is in use.

Benzodiazepines are administered every 4 hr.

A family member remains at the client's bedside 24 hr each day.

Answer and Explanation

The Correct Answer is A

A. An assistive personnel is encouraging intake of oral fluids: For a client in the active dying phase, forcing or encouraging oral intake can cause discomfort, aspiration, or fluid overload. The focus should be on comfort rather than meeting standard hydration goals, so this requires intervention by the nurse.

B. Supplemental oxygen is in use: Oxygen may be provided for comfort if the client experiences dyspnea. Its use in the active dying phase is appropriate and does not require intervention unless it causes discomfort or is unnecessary.

C. Benzodiazepines are administered every 4 hr: Scheduled benzodiazepines can help manage anxiety, restlessness, or dyspnea in a dying client. This is an appropriate intervention for comfort and does not require nurse intervention.

D. A family member remains at the client's bedside 24 hr each day: Continuous presence of family provides emotional support and comfort for both the client and loved ones. This is consistent with hospice care principles and does not require nurse intervention.

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Correct Answer is A

Explanation

A. Wear cotton underwear: Cotton underwear allows better air circulation and reduces moisture accumulation, which helps prevent bacterial growth in the genital area. Proper underwear choice is a simple preventive measure that supports urinary tract health.

B. Drink orange juice daily for 3 to 4 weeks: While vitamin C may help acidify urine slightly, there is no evidence supporting long-term consumption specifically for UTI prevention. Excessive intake can also irritate the bladder or cause gastrointestinal upset.

C. Take the prescribed antibiotic until manifestations are gone: Antibiotics should be taken for the full prescribed course, not just until symptoms resolve. Stopping early can lead to incomplete eradication of bacteria and increase the risk of resistance.

D. Restrict fluid intake to 1 L per day: Restricting fluids can worsen UTIs by reducing urine output, which limits bacterial flushing from the urinary tract. Adequate hydration is recommended to help prevent and manage UTIs.

A. Heart rate B. Pedal pulses C. Breath sounds D. Abdominal dressing E. Respiratory rate F. Oxygen saturation

Correct Answer is ["A","D","E"]

Explanation

A. Heart rate: The increase from 88/min to 110/min indicates tachycardia, which can be an early sign of hypovolemia, infection, or sepsis. When combined with hypotension and fever, this finding suggests possible postoperative complications requiring urgent evaluation.

B. Pedal pulses: Bilateral pedal pulses remain 2+, indicating adequate peripheral perfusion at this time. This finding is stable and does not suggest acute circulatory compromise requiring immediate follow-up.

C. Breath sounds: Breath sounds are clear and unchanged from admission, suggesting no current pulmonary complication such as atelectasis or pneumonia. This finding does not indicate an urgent problem.

D. Abdominal dressing: A sudden increase to a large amount of serosanguinous drainage after the client felt something “pop” raises concern for wound dehiscence or possible evisceration. This is a surgical emergency requiring immediate assessment and intervention.

E. Respiratory rate: The respiratory rate has increased from 18/min to 24/min, indicating tachypnea. This may reflect pain, infection, or developing sepsis and warrants prompt follow-up in the postoperative client.

F. Oxygen saturation: Oxygen saturation remains within an acceptable range at 95% on room air. Although it should continue to be monitored, it does not currently indicate acute respiratory compromise.

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A nurse on a hospice unit is caring for a client who has cancer and is in the active phase of dying. Which of the following findings requires intervention by the nurse?

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Naxlex Comprehensive Predictor Exams

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