The hospice nurse is teaching the family of a client receiving palliative care at home how to provide care. Which instruction should the nurse provide?

Report any change in urine color.

Maintain in high Fowler's position.

Keep mucous membranes moist.

Record the client's daily weights.

Answer and Explanation

The Correct Answer is C

Choice A reason: Reporting any change in urine color is important but not specific to the provision of palliative care at home.

Choice B reason: Maintaining in high Fowler's position is not always necessary and may not be comfortable for all clients, especially in a palliative care setting.

Choice C reason: Keeping mucous membranes moist helps prevent discomfort and is a key part of providing compassionate end-of-life care.

Choice D reason: Recording the client's daily weights is less relevant in palliative care, where the focus is on comfort rather than ongoing medical assessments.

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Correct Answer is C

Explanation

Choice A reason: Decreased bowel sounds may indicate gastrointestinal issues but are not directly related to weight gain associated with fluid accumulation in cirrhosis.

Choice B reason: An increased respiratory rate can be a sign of many conditions, including respiratory distress, but it does not correlate specifically with weight gain due to fluid retention in cirrhosis.

Choice C reason: Increased abdominal girth is a common finding in cirrhosis due to ascites, which is the accumulation of fluid in the peritoneal cavity and can lead to significant weight gain.

Choice D reason: Decreased level of consciousness may be a sign of hepatic encephalopathy in cirrhosis but is not a direct correlation to the weight gain reported by the client.

A. Measure urinary output to ensure renal functioning. B. Administer the oral analgesic medication an hour before discontinuing the PCA pump. C. Monitor for a depressed respiratory rate. D. Teach about the need to progress to a high-fiber diet.

Correct Answer is B

Explanation

Choice A reason: Measuring urinary output is important for monitoring renal function, especially when using medications like morphine, but it is not the most critical intervention in this context.

Choice B reason: Administering the oral analgesic before discontinuing the PCA allows for the medication to take effect, preventing breakthrough pain and addressing the client's fear of pain.

Choice C reason: Monitoring for a depressed respiratory rate is crucial when a patient is on morphine, but the priority is to manage pain effectively as the client transitions to oral analgesics.

Choice D reason: Education on dietary needs is important for long-term recovery, but immediate pain management is a higher priority in the postoperative period.

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The hospice nurse is teaching the family of a client receiving palliative care at home how to provide care. Which instruction should the nurse provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is B

Explanation

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