The practical nurse (PN) is visiting a client who has stage four colon cancer and is receiving palliative home care. The client refuses to eat and sleeps most of the day. Which intervention should the nurse ask the PN to ensure the family is providing the client?
Maintain in high Fowler's position.
Report any change in urine color.
Keep mucous membranes moist.
Record the client's daily weight.
The Correct Answer is C
Choice A reason: Maintaining in high Fowler's position may help the client breathe easier, but it is not the most important intervention. The client may prefer to lie down or change positions according to their comfort.
Choice B reason: Reporting any change in urine color may indicate dehydration, infection, or kidney problems, but it is not the most important intervention. The client may not have much urine output due to reduced fluid intake and kidney function.
Choice C reason: Keeping mucous membranes moist is the most important intervention, as it can prevent dryness, cracking, and bleeding of the lips, mouth, and throat. The client may have difficulty swallowing and may lose their sense of taste due to the cancer or the treatment. The PN should encourage the family to offer the client sips of water, ice chips, or mouthwash, and to apply lip balm or petroleum jelly.
Choice D reason: Recording the client's daily weight may help monitor the client's nutritional status and fluid balance, but it is not the most important intervention. The client may have significant weight loss due to the cancer or the treatment, and may not want to eat or drink. The PN should respect the client's wishes and not force them to eat or drink.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: How many departments can use this equipment is not the most important question to consider when analyzing the cost-benefit for this piece of equipment. This question may be relevant for determining the utilization and availability of the equipment, but it does not directly address the cost or the benefit of the equipment.
Choice B reason: Can the equipment be updated each year is not the most important question to consider when analyzing the cost-benefit for this piece of equipment. This question may be relevant for determining the longevity and compatibility of the equipment, but it does not directly address the cost or the benefit of the equipment.
Choice C reason: Is the cost of equipment reasonable is the most important question to consider when analyzing the cost-benefit for this piece of equipment. This question directly addresses the cost of the equipment and compares it to the expected benefit of the equipment. A reasonable cost means that the equipment is worth the investment and will provide a positive return on value.
Choice D reason: Will the equipment require annual repair is not the most important question to consider when analyzing the cost-benefit for this piece of equipment. This question may be relevant for determining the maintenance and reliability of the equipment, but it does not directly address the cost or the benefit of the equipment.
Correct Answer is C
Explanation
Choice A reason: Calling the client's next of kin and having them provide verbal consent is not the appropriate action for the nurse to take. The client is an adult and has the right to make his own decisions about his health care. The nurse should respect the client's autonomy and not involve his family without his permission.
Choice B reason: The nurse can reinforce information but cannot provide the primary explanation of the procedure. The HCP must clarify any confusion before consent is valid.
Choice C reason: Informed consent requires that the client fully understands the procedure, risks, benefits, and alternatives before signing. The healthcare provider (HCP) is responsible for explaining the procedure, not the nurse. Since the client’s question indicates misunderstanding, the nurse must notify the provider so they can clarify the information before consent is obtained.
Choice D reason: Postponing the procedure until the client understands the risks/benefits is not the best action for the nurse to take. The cardiac catheterization may be a time-sensitive and necessary procedure for the client's condition. The nurse should not delay the procedure without a valid reason. The nurse should try to enhance the client's understanding and confidence before postponing the procedure.
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