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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Consulting the palliative care team is an important action for the nurse to take, but not the first one. The palliative care team can provide holistic and compassionate care to the client and the family and help them cope with the end-of-life issues. However, the nurse should first obtain a do not resuscitate prescription from the healthcare provider to ensure that the client's wishes are respected and followed.
Choice B reason: Obtaining a do not resuscitate prescription is the first action for the nurse to take. The do not resuscitate prescription is a legal document that states that the client does not want any cardiopulmonary resuscitation or other life-sustaining interventions in the event of cardiac or respiratory arrest. The nurse should obtain the prescription from the healthcare provider and document it in the client's chart. The nurse should also inform the staff and the family about the prescription and its implications.
Choice C reason: Defining the term heroic measures is not the first action for the nurse to take. The term heroic measures is vague and subjective and may mean different things to different people. The nurse should clarify with the client and the family what they consider as heroic measures and what they want to avoid or accept. However, the nurse should first obtain a do not resuscitate prescription to ensure that the client's wishes are legally binding and clear.
Choice D reason: Coordinating a family conference is not the first action for the nurse to take. The family conference is a meeting where the client, the family, the healthcare provider, and the nurse can discuss the goals and plans of care and address any concerns or questions. The family conference can facilitate communication and decision-making and promote mutual understanding and support. However, the nurse should first obtain a do not resuscitate prescription to ensure that the client's wishes are honored and communicated.
Correct Answer is A
Explanation
Choice A reason: Calling for an assistant is the best action for the nurse to take. This can help the nurse maintain aseptic technique and ensure the safety of the client undergoing the lumbar puncture, while also allowing the nurse to respond to the code as soon as possible.
Choice B reason: Responding to the code is not the best action for the nurse to take. This may compromise the aseptic technique and the safety of the client undergoing the lumbar puncture, who may also experience complications or adverse reactions.
Choice C reason: Closing the room door is not the best action for the nurse to take. This may isolate the client undergoing the lumbar puncture and prevent the nurse from communicating or receiving assistance from other staff members.
Choice D reason: Finishing the procedure is not the best action for the nurse to take. This may delay the nurse's response to the code and jeopardize the survival of the client experiencing respiratory arrest, who needs immediate and effective resuscitation.
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