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

Explanation

C. Intradermal injections are administered into the dermal layer of the skin, just below the epidermis. Ensuring that the bevel of the needle is pointing up helps facilitate proper placement of the medication into the dermal layer and improves accuracy.
A. Intradermal injections are typically administered on the inner forearm or the upper back, not the upper arm.
B. When administering an intradermal injection, the nurse should hold the syringe at a shallow angle (approximately 5-15 degrees) to the skin, not perpendicular. Holding the syringe perpendicular would increase the risk of inserting the needle too deeply, which could lead to improper administration of the medication.
D. Massaging the site can cause the medication to disperse into the subcutaneous tissue, potentially affecting the accuracy of the test.

A. Criminal assault and battery. B. Good Samaritan immunity. C. Negligent acts of omission. D. Abandonment of the victim.

Correct Answer is B

Explanation

A. Assault and battery involve intentional harmful or offensive contact with another person without their consent. Criminal assault is the threat of harm, while battery is the actual physical contact.
In this scenario, the nurse's actions were aimed at providing assistance to the victim, not causing harm. Therefore, criminal assault and battery would not apply.
B. Good Samaritan immunity protects individuals who provide assistance in emergency situations from liability for any injuries or damages that may occur as a result of their actions, as long as they act in good faith and without expectation of compensation. In this scenario, the nurse stopped to provide assistance voluntarily and acted in the victim's best interest. Good Samaritan immunity would likely apply in this situation, protecting the nurse from liability for any unintended consequences of their actions.
C. In this scenario, if the nurse failed to provide necessary care or took actions that deviated from the standard of care expected in similar circumstances, it could be considered negligent. However, the specific concern in this scenario is more aligned with abandonment of the victim rather than negligent acts of omission.

D. Abandonment occurs when a healthcare provider discontinues care without ensuring that the patient's needs are met or transferring care to another qualified individual. In this scenario, the nurse reported the victim's condition to EMS before leaving the scene. The nurse did not abandon the victim as they ensured that the victim received ongoing care from EMS.

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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

The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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