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 B

Explanation

B. Hyperkalemia can lead to cardiac dysrhythmias, including bradycardia, heart block, or ventricular fibrillation, which can be life-threatening. Therefore, assessing the client's apical pulse rate and rhythm is crucial to identify any cardiac changes and promptly intervene if necessary.
A. Changes in urine output and characteristics may indicate renal involvement in hyperkalemia. However, monitoring urinary output alone may not provide immediate information about the client's cardiac status or the severity of hyperkalemia.
C. Assessing deep tendon reflexes is important in evaluating for neurological manifestations of hyperkalemia. However, changes in reflexes may not be immediately indicative of the severity of hyperkalemia or its potential cardiac effects.
D. Assessing muscle strength is important in evaluating for neuromuscular manifestations of hyperkalemia, changes in muscle strength may not provide immediate information about the client's cardiac status or the severity of hyperkalemia.

A. Review the pain medications prescribed. B. Administer PRN oral pain medication. C. Ask the client what is causing the grimacing. D. Monitor the client's nonverbal behavior.

Correct Answer is D

Explanation

D. Nonverbal behavior, the nurse can gather further information about the presence and intensity of pain. This includes observing facial expressions, body movements, and any other signs of discomfort. It's important to recognize that individuals may not always verbalize their pain for various reasons, such as fear of medication side effects, concerns about being a burden, or communication barriers.
A. Reviewing the pain medications is important but it may not be the immediate priority in this scenario, as the client is currently experiencing pain-related grimacing.
B. Administering pain medication without further assessment of the client's pain or understanding the cause of the grimacing may not address the underlying issue contributing to the client's discomfort.
C. While communication with the client is important, asking about the cause of the grimacing may not provide accurate information, especially if the client is denying pain. Nonverbal cues such as grimacing suggest the presence of pain, which may not be fully acknowledged by the client.

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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?

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Naxlex Comprehensive Predictor Exams

When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement? Reference Range: Potassium (3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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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?