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 B
Explanation
The correct answer is B. Encourage the nurse to share her concerns and discuss ways to prepare for such emergencies.
Choice A: Ask the nurse why she thinks there is no need for an in-service program about these emergencies.
This response might come across as confrontational and could potentially escalate the situation. It puts the nurse on the defensive and does not foster a collaborative environment. Instead of addressing the nurse’s concerns, it questions her judgment, which might not be the most effective way to manage the situation.
Choice B: Encourage the nurse to share her concerns and discuss ways to prepare for such emergencies.
This approach is the most constructive and supportive. It opens a dialogue, allowing the nurse to express her concerns and feel heard. By discussing the importance of bioterrorism preparedness and finding ways to address any issues she might have, the nurse-manager can foster a more positive and cooperative atmosphere. This method aligns with effective communication and conflict resolution strategies in healthcare management.
Choice C: Choose to send another nurse who is more receptive because the older nurse is not interested.
This option avoids addressing the underlying issue and could be seen as dismissive. It does not resolve the nurse’s concerns and might lead to further dissatisfaction or disengagement. Additionally, it does not promote a culture of continuous learning and improvement, which is crucial in healthcare settings.
Choice D: Inform the older nurse that in-service is not optional and her scheduled attendance is mandatory.
While this response is direct and enforces the rules, it lacks empathy and does not address the nurse’s concerns. It might lead to resentment and a negative work environment. Effective management involves understanding and addressing employees’ concerns, not just enforcing rules.
Correct Answer is C
Explanation
Choice A reason: Providing the UAP with the infection control policy is not the first action the charge nurse should take. The charge nurse should first assess the UAP's knowledge and understanding of HIV transmission and infection control measures.
Choice B reason: Offering to assist the UAP with the collection of the specimen is not the first action the charge nurse should take. The charge nurse should first address the UAP's fear and educate the UAP about HIV transmission and infection control measures.
Choice C reason: Determining the UAP's knowledge about HIV transmission is the first action the charge nurse should take. This will help the charge nurse identify any knowledge gaps or misconceptions the UAP may have and provide appropriate education and reassurance.
Choice D reason: Demonstrating the proper use of personal protective equipment is not the first action the charge nurse should take. The charge nurse should first assess the UAP's knowledge and understanding of HIV transmission and infection control measures.
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