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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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. Share personal values to put the client at ease. B. Ask questions in a vague, nonspecific format. C. Get the most difficult questions over with first. D. Begin with questions that are less sensitive in nature.

Correct Answer is D

Explanation

D. Starting with less sensitive questions allows the nurse to establish rapport with the client and create a comfortable environment before addressing more sensitive topics. This approach helps build trust and encourages the client to open up about their concerns regarding sexual activity.
A. Sharing personal values may not be appropriate as it could potentially introduce bias or make the client feel uncomfortable if their values differ from those of the nurse.
B. Asking vague or nonspecific questions may result in incomplete or unclear information from the client, leading to ineffective assessment and care planning.
C. Starting with the most difficult questions may cause the client to feel overwhelmed or defensive, hindering open communication.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Naxlex Comprehensive Predictor Exams

Which client assessment should the nurse perform during nasopharyngeal suctioning?

Correct Answer is D

Explanation

The nurse is interviewing a client with lower abdominal pain and dysuria, and needs to question the client about sexual activity. Which approach is best for the nurse to use?

Correct Answer is D

Explanation

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

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?

The nurse observes the unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

When assuming care of a client at 1900, the nurse learns in report that a client with a urinary tract infection had an indwelling urinary catheter removed during the previous shift. Which information is most important for the nurse to obtain?

A client with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage?