Author Question: For a client in the final stages of dying, a nurse expects to: A. Keep the client cool B. ... (Read 77 times)

silviawilliams41 · **on:** Jul 24, 2018

For a client in the final stages of dying, a nurse expects to:

A. Keep the client cool
B. Catheterize the client on a regular basis
C. Elevate the head of the bed as tolerated
D. Encourage the client to eat and drink more

Question 2

An appropriate procedure for the nurse to implement when pouching an enterostomy is to:

A. Add aspirin to the pouch to decrease odors
B. Remove the skin barrier quickly and firmly
C. Use a high-output pouch for an ileostomy
D. Cut the pouch opening to 1 inch larger than the stoma

maaaaaaaaaa · **Reply #1 on:** Jul 24, 2018

Answer to Question 1

C
C. The client experiences poor circulation of body fluids, immobilization, and inability to expectorate secretions, which cause rattles and bubbling. Elevate the head with pillow or raise the head of the bed; gently turn head to side to drain secretions.
A. Coolness, color, and temperature changes in hands, arms, legs and feet may be present. Place socks on feet. Cover with light cotton blanket. Keep warm blankets on client.
B. The client may have incontinence of urine, bowel, or both. Change bedding as appropriate. Avoid use of indwelling catheter.
D. There is decreased intake of food and fluids. Do not force client to eat or drink, give ice chips, soft drinks, juice, as possible. Provide mouth care.

Answer to Question 2

C
C. If client has large amount of liquid stool from an ileostomy, consider using a high-output pouch that will contain this effluent and reduce frequency of pouch emptying.
A. Although many ostomy pouches are odor-proof, some nurses and clients like to add a small amount of ostomy deodorant into pouch. Do not use home remedies, which can harm stoma, to control ostomy odor.
B. Remove existing pouch, if any, by gently pushing skin from adhesive barrier; properly dispose of soiled pouch
D. Select appropriate pouch for client based on client assessment. With a custom cut-to-fit pouch, use an ostomy guide to cut opening on the pouch 1/16 to 1/8 inch larger than stoma before removing backing.