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    Hesi RN Foundation Of Nursing Proctored Exam

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    Question: 1 of 55Hesi rn foundation of nursing proctored exam
    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?
    Explanation
    A. High Fowler’s position is useful for respiratory distress, but this client’s primary issue is dehydration and mouth breathing, so oral care takes precedence. B. Monitoring urine color is part of general assessment, but changes in urine are expected in terminally ill clients due to decreased intake. This is not a priority comfort measure. C. Daily weights assess fluid status but are unnecessary for a terminally ill client focusing on comfort measures rather than aggressive treatment. D. Keeping mucous membranes moist is a priority intervention for comfort care in a terminally ill client. Weakness, mouth breathing, and refusal to eat or drink can cause dehydration and dry mucosa, leading to discomfort. Providing oral care, lip moisturizer, and ice chips (if appropriate) can alleviate dryness and promote comfort.
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