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. Encouraging the client to visualize positive external places, such as peaceful landscapes, serene beaches, or tranquil gardens, can help distract from the pain and promote relaxation. This focus can help shift the client's attention away from the pain sensation, potentially reducing its intensity and improving overall comfort.
B. Tranquil sounds can be utilized but are not a form of guided imagery.

C. Emotional reflection (choice C) may not directly contribute to pain relief during guided imagery sessions.
D. Incorporating motivational phrases during guided imagery can help boost the client's mood, enhance self-confidence, and foster a positive mindset, which may contribute to pain relief and overall well- being. However, positive external places should be the primary focus.

A. Use positive reinforcement to affirm that the procedure is being performed correctly. B. Advise the UAP to hold the thermometer securely in place for a full three minutes. C. Demonstrate the correct technique for pulling the client's auricle down and back. D. Remind the UAP to lubricate the thermometer before gently inserting in the ear.

Correct Answer is A

Explanation

A. When using a tympanic thermometer on an adult client, the correct technique involves pulling the auricle up and back to straighten the ear canal, which the UAP is doing correctly.

B. Tympanic thermometers typically only require a few seconds to obtain a temperature reading, not three minutes. Advising the UAP to hold the thermometer in place for three minutes would be incorrect and unnecessary.

C.This technique is used for children under three years old, not adults.
D. Lubricating the tympanic thermometer before insertion is not typically necessary, as most tympanic thermometers are designed to be used without lubrication.

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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 using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client's attention on which focus?

Correct Answer is A

Explanation

The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?

Correct Answer is A

Explanation

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