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 ["C","D"]

Explanation

Immediate documentation after drug administration ensures the everyone who comes into contact with the client is aware of what has already been done

Ensuring the client does the administration also avoids such errors. The client is able to understand and question when too many doses are given without proper explanation.

A. Bears body weight on the palms of hands during the crutch gait. B. Progresses to foot touchdown and weight bearing of affected leg. C. Practices bicep and triceps isometric exercises. D. Inspects crutches to ensure rubber tips are intact.

Correct Answer is B

Explanation

A. This choice suggests an incorrect technique. Proper crutch walking technique involves bearing weight on the hands through the hand grips of the crutches rather than the palms. Placing excessive weight on the palms can lead to discomfort, injury, and improper weight distribution, which could hinder effective ambulation.
B. This choice indicates that the client understands proper crutch walking because it involves the correct progression of weight-bearing on the affected leg while using the crutches for support. In the three-point gait crutch walking technique, the client progresses by first touching down the foot of the affected leg and then transferring weight onto that leg while stepping forward with the crutches. This behavior ensures proper balance and support during ambulation.
C. is beneficial for muscle strength but not directly related to the technique of crutch walking.
D. Ensuring rubber tips are intact and practicing muscle exercises are important, but they do not demonstrate the actual process of walking with the crutches.

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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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Correct Answer is ["C","D"]

Explanation

The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?

Correct Answer is B

Explanation

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