Patient Data

Exhibits

Which intervention should the nurse prioritize for this client?

Administer pain medication as prescribed.

Provide emotional support to the family.

Assist with daily activities.

Monitor vital signs regularly.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Administering pain medication as prescribed is the priority intervention for a client receiving hospice care with significant pain and discomfort. Effective pain management is essential to ensure the client’s comfort and quality of life. Pain relief is a primary goal in hospice care, and regular administration of pain medication helps manage symptoms and improve the client’s overall well-being.

Choice B rationale

Providing emotional support to the family is important in hospice care, as families often need assistance coping with the emotional challenges of caring for a loved one with a terminal illness. However, the priority intervention is to manage the client’s pain and discomfort effectively.

Choice C rationale

Assisting with daily activities is necessary for clients with limited mobility, but it is not the primary intervention. Ensuring the client’s comfort and pain relief takes precedence, as it directly impacts their quality of life.

Choice D rationale

Monitoring vital signs regularly is part of the overall care plan, but it is not the priority intervention. The focus should be on managing the client’s pain and discomfort to provide the best possible quality of life in hospice care.

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Correct Answer is B

Explanation

Choice A rationale

Reporting any change in urine color is not a priority intervention for a terminally ill client who is weak, mouth breathing, and refusing anything to eat or drink. The focus should be on comfort measures.

Choice B rationale

Keeping mucous membranes moist is essential for comfort in terminally ill clients who are mouth breathing and refusing fluids. This can be achieved by offering ice chips, sips of water, or using a moist cloth.

Choice C rationale

Recording the client’s daily weight is not a priority in this situation as the client is terminally ill and the focus should be on comfort rather than monitoring weight.

Choice D rationale
Maintaining the client in high Fowler’s position is not necessary unless it helps with breathing. The priority is to keep the client comfortable.

A. Tests for a gag reflex before performing oral care. B. Places the client in a supine position. C. Suctions secretions from the posterior pharynx. D. Uses an oral airway to keep the teeth apart.

Correct Answer is B

Explanation

Choice A rationale

Testing for a gag reflex before performing oral care is a standard practice to ensure the client’s safety and prevent aspiration. This action does not indicate a need for additional training.

Choice B rationale

Placing the client in a supine position is incorrect and indicates a need for additional training. The correct position for performing oral care on an unconscious client is a side-lying position to prevent aspiration and ensure secretions can drain from the mouth.

Choice C rationale

Suctioning secretions from the posterior pharynx is a necessary action to maintain airway patency and prevent aspiration. This action does not indicate a need for additional training.

Choice D rationale

Using an oral airway to keep the teeth apart is a standard practice to facilitate oral care and prevent the client from biting down on the caregiver’s fingers or equipment. This action does not indicate a need for additional training.

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Patient Data Exhibits Which intervention should the nurse prioritize for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The palliative care nurse receives a consult for a terminally ill client in the intensive care unit. The client is weak, mouth breathing, and refusing anything to eat or drink. Which intervention should the nurse include in the plan of care?

Correct Answer is B

Explanation

The nurse observes a practical nurse (PN) performing oral care on an unconscious client. Which action by the PN indicates to the nurse the need for additional training?

Correct Answer is B

Explanation

A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?

The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?

A client with chronic fecal incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which intervention should the nurse implement?

An older adult client with heart failure has a signed do not resuscitate (DNR) form in the medical record. The unlicensed assistive personnel (UAP) reports that the client is not breathing, and the nurse confirms the UAP’s findings. Which action should the nurse take next?

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?

A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?

The nurse is reviewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client’s plan of care? Select all that apply.

Patient Data

Exhibits

Which intervention should the nurse prioritize for this client?