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 in the plan of care?
Report any change in urine color.
Keep mucous membranes moist.
Record the client’s daily weight.
Maintain in high Fowler’s position.
The Correct Answer is B
Choice A rationale
Reporting any change in urine color is not a priority intervention for a terminally ill client who is weak, mouth breathing, and refusing anything to eat or drink. The focus should be on comfort measures.
Choice B rationale
Keeping mucous membranes moist is essential for comfort in terminally ill clients who are mouth breathing and refusing fluids. This can be achieved by offering ice chips, sips of water, or using a moist cloth.
Choice C rationale
Recording the client’s daily weight is not a priority in this situation as the client is terminally ill and the focus should be on comfort rather than monitoring weight.
Choice D rationale
Maintaining the client in high Fowler’s position is not necessary unless it helps with breathing. The priority is to keep the client comfortable.
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Correct Answer is B
Explanation
Choice A rationale
Testing for a gag reflex before performing oral care is a standard practice to ensure the client’s safety and prevent aspiration. This action does not indicate a need for additional training.
Choice B rationale
Placing the client in a supine position is incorrect and indicates a need for additional training. The correct position for performing oral care on an unconscious client is a side-lying position to prevent aspiration and ensure secretions can drain from the mouth.
Choice C rationale
Suctioning secretions from the posterior pharynx is a necessary action to maintain airway patency and prevent aspiration. This action does not indicate a need for additional training.
Choice D rationale
Using an oral airway to keep the teeth apart is a standard practice to facilitate oral care and prevent the client from biting down on the caregiver’s fingers or equipment. This action does not indicate a need for additional training.
Correct Answer is C
Explanation
Choice A rationale
Negligence would require proof that the nurse failed to act in a manner consistent with their training and that this failure directly caused harm to the victim. In this case, the nurse provided assistance and then left the scene after EMS arrived, which does not constitute negligence.
Choice B rationale
Assault and battery involve intentional harm or offensive contact, which is not applicable in this scenario as the nurse was providing assistance.
Choice C rationale
The Good Samaritan laws are designed to protect individuals who provide assistance at the scene of an emergency from legal liability, provided they act in good faith and within the scope of their training. In this scenario, the nurse acted to help the victim and then left the scene after EMS arrived, which is generally protected under Good Samaritan laws.
Choice D rationale
Abandonment would require that the nurse left the victim without ensuring that they were in the care of another competent individual. Since the nurse left after EMS arrived, this does not constitute abandonment.