An older adult woman with end stage heart disease is alert and oriented and states that she does not want any heroic measures taken in the event she stops breathing. The client's children tell the nurse that they accept their mother's wishes and do not want to watch her suffer. Which action should the nurse take first?

Choice A reason: Maintaining in high Fowler's position may help the client breathe easier, but it is not the most important intervention. The client may prefer to lie down or change positions according to their comfort.

Choice B reason: Reporting any change in urine color may indicate dehydration, infection, or kidney problems, but it is not the most important intervention. The client may not have much urine output due to reduced fluid intake and kidney function.

Choice C reason: Keeping mucous membranes moist is the most important intervention, as it can prevent dryness, cracking, and bleeding of the lips, mouth, and throat. The client may have difficulty swallowing and may lose their sense of taste due to the cancer or the treatment. The PN should encourage the family to offer the client sips of water, ice chips, or mouthwash, and to apply lip balm or petroleum jelly.

Choice D reason: Recording the client's daily weight may help monitor the client's nutritional status and fluid balance, but it is not the most important intervention. The client may have significant weight loss due to the cancer or the treatment, and may not want to eat or drink. The PN should respect the client's wishes and not force them to eat or drink.

Choice A reason: Providing revised procedural updates through additional nursing staff education programs is not the best action for the nurse manager to take. The nurse manager should first evaluate the effectiveness of the current policies and education programs before implementing any changes. The nurse manager should also involve the nursing staff in the process of revising the policies and education programs.

Choice B reason: Examining medication administration data to determine use of new policy by nursing staff is the best action for the nurse manager to take. The nurse manager should analyze the data to identify the types, causes, and frequency of medication errors and compare them with the previous data. The nurse manager should also assess the compliance and feedback of the nursing staff regarding the new policies. This will help the nurse manager to identify the gaps and barriers in the implementation of the new policies and plan appropriate interventions.

Choice C reason: Investigating identified procedural variances in medication administration with nursing staff is an important action for the nurse manager to take, but not the best one. The nurse manager should first examine the medication administration data to determine the extent and nature of the procedural variances. The nurse manager should then investigate the specific cases of variances with the nursing staff and provide constructive feedback and guidance.

Choice D reason: Determining changes in procedure needed to reduce the frequency of medication errors is a desirable outcome for the nurse manager, but not the best action to take. The nurse manager should first examine the medication administration data and investigate the procedural variances before making any changes in the procedure. The nurse manager should also consult with the healthcare provider, the pharmacist, and the quality improvement team to ensure that the changes are evidence-based and feasible.