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 D

Explanation

D. Edema of the fingers and hands can impair circulation and peripheral perfusion, which may affect the accuracy of oxygen saturation readings obtained from a pulse oximeter. Edema can interfere with the transmission of light through the tissues, leading to inaccurate readings.
A. A strong radial pulse volume indicates adequate peripheral perfusion and may not directly contribute to a lower oxygen saturation reading.
B. A capillary refill time within the normal range (typically less than 2 seconds) suggests adequate peripheral circulation and may not directly contribute to a lower oxygen saturation reading.
C. While hypertension can potentially affect oxygen saturation through its impact on systemic vascular resistance and tissue perfusion, a blood pressure of 142/88 mm Hg alone may not significantly contribute to a lower oxygen saturation reading.

A. "We will give you a class on dressing tomorrow." B. "Dressing must be a frustrating experience for you." C. "This unit has a policy against staff harassment." D. "It is important to dress the right arm first."

Correct Answer is B

Explanation

B. This response demonstrates empathy and acknowledges the client's frustration without condoning or reacting defensively to their cursing. It validates the client's feelings and opens the door for further communication about their needs and concerns.
A. This response acknowledges the client's struggle and offers a solution for future assistance with dressing. However, it may not effectively address the client's current frustration and emotional distress.
C. This response addresses inappropriate behavior but does not directly address the client's frustration or provide support for their current situation.
D. This response focuses on the technical aspect of dressing and does not address the client's emotional distress or frustration. It may come across as dismissive of the client's feelings.

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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 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?

Correct Answer is D

Explanation

A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which response is best for the nurse to provide?

Correct Answer is B

Explanation

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