A nurse aide reports to the nurse that the 87-year-old client is not breathing well and has cold and mottled skin. The client has a living will and requests comfort measures only. The nurse's action to care for this client would be to:

Question

1. Withhold pain medication, hygiene, and nutrition until the client dies.
2. Contact the physician for orders to control the client's breathing.
3. Ask the family what they want to be done for the client.
4. Instruct the nurse aide to provide personal hygiene and skin care as outlined in the care plan.

Answer 1

4. Instruct the nurse aide to provide personal hygiene and skin care as outlined in the care plan.

Rationale:
Comfort measures only indicate that the client does not want extraordinary measures to sustain life. This does not mean that nursing care ceases but that nursing care to provide patient comfort is intensified and maintained through the end stages of the client's life. Withholding pain medication, hygiene, and nutrition would be neglecting the patient and not providing comfort measures. Asking the family what they want to be done is inappropriate when a client has written a living will. Contacting the physician to intervene to control respiration is considered adding extraordinary measures and is inappropriate, as is going against the client's written wishes when a living will is present and in force.