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 plan of care?

Keep mucous membranes moist.

Record the client's daily weight.

Maintain in high Fowler's position.

Report any change in urine color.

Answer and Explanation

The Correct Answer is A

A. Keeping the mucous membranes moist is essential for comfort and preventing discomfort associated with dryness, especially in a client who is weak and mouth breathing. This intervention can help prevent issues such as dry mouth, cracked lips, and irritation of the oral mucosa, which can contribute to discomfort and difficulty swallowing.
B.   Monitoring the client's weight can provide valuable information about fluid balance and nutritional status but in the context of a terminally ill client who is weak and refusing to eat or drink, daily weight monitoring may not be as relevant or informative.
C.   The high Fowler's position is often used to improve breathing comfort and lung expansion in clients experiencing respiratory distress. However, in a terminally ill client who is weak and mouth breathing, maintaining them in a high Fowler's position may not be necessary or comfortable.

D.   While monitoring urine output and characteristics is important for assessing renal function and hydration status, changes in urine color may not be a priority in the care of a terminally ill client who is weak and not consuming fluids.

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Correct Answer is D

Explanation

D. Assessing the client's skin and mucous membranes can provide valuable information about oxygenation, circulation, and hydration status, which are relevant during and after nasopharyngeal suctioning. Changes in skin color, moisture, and mucous membrane appearance can indicate respiratory distress, hypoxia, or inadequate hydration.
A. Skin turgor assessment is typically used to evaluate hydration status and is not directly relevant to nasopharyngeal suctioning.
B. Bowel sounds assessment is not directly related to nasopharyngeal suctioning and is not a priority during this procedure.
C. Palpating pedal pulses is a method of assessing peripheral circulation and is not directly relevant to nasopharyngeal suctioning.

A. Review the advanced directive document. B. Irrigate the nasogastric tube with water. C. Elevate the head of bed 45 degrees. D. Perform oropharyngeal suctioning.

Correct Answer is D

Explanation

A. Reviewing the advance directive is important but not the immediate priority in an acute situation.
B. Irrigating the nasogastric (NG) tube with water is not the priority action in this scenario.

C. Elevating the head does no address teh client's concern of choking and risk of apiration,
D. Performing oropharyngeal suctioning prevents aspiration of gastric content into the airway

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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 plan of care?

Nursing Test Bank

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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 plan of care?