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 A

Explanation

A. It is crucial to assess whether the client has been able to void successfully after catheter removal. The ability to void indicates that the urinary system is functioning properly and that there are no immediate complications such as urinary retention. If the client has not voided within an appropriate timeframe after catheter removal, further assessment and intervention may be necessary to prevent urinary retention or other urinary complications.

B. Understanding the client's fluid balance is essential, especially after catheter removal. However, it does not provide significant information on the client’s ability to void.
C. While the color of urine can provide insights into hydration and potential issues like hematuria, it's not as immediately critical as knowing if the client has successfully voided after catheter removal.
D. This information is relevant for monitoring antibiotic therapy but may not be as urgent as understanding the client's urinary status after catheter removal.

A. Completing discharge teaching to a client and family members. B. Offering therapeutic support and comfort to a grieving family. C. Obtaining clarification from a client's healthcare power-of-attorney. D. Reporting a change in a client's condition to the healthcare provider.

Correct Answer is D

Explanation

D. The Situation, Background, Assessment, and Recommendation (SBAR) format of communication is commonly used in healthcare settings to facilitate effective and concise communication, especially when reporting critical information.
A. While effective communication is essential during discharge teaching to ensure that the client and family members understand the instructions and follow-up care, the SBAR format is not typically used in this context.
B. When offering therapeutic support and comfort to a grieving family, the focus is on empathy, active listening, and providing emotional support.
C. When obtaining clarification from a client's healthcare power-of-attorney, it's important to ensure that information is communicated accurately and any questions or concerns are addressed.

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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

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?

Correct Answer is D

Explanation

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