The nurse caring for a client with a terminal illness in the long-term care facility talks with the client during the morning bath
After lunch, the nurse finds the client difficult to arouse, with cool cyanotic hands and mottling of the lower extremities. The nurse's priority action is to: 1. Notify the family that the client's death is imminent.
2. Notify the physician of the change in the client's condition.
3. Call 911 to have the client transferred to the acute care facility.
4. Attempt to stimulate the client to increase activity in order to improve perfusion.
1
Rationale: The client is showing signs of imminent death, and the nurse should notify those family members or friends who would want to be with the client at the time of death. There is no need to transfer the client to an acute care facility if the client does not wish to be resuscitated, which is fairly standard for those with a terminal illness. The physician does not need to be notified unless orders were written to notify of impending death, which is not customary. The terminal client's life would not be prolonged by stimulation, nor should it be.
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