A client with metastatic cancer reports a pain level of 10 on a pain scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which intervention is most important for the nurse to include in this client’s plan of care?

Administer analgesics on a fixed and continuous schedule.

Frequently evaluate the client’s pain.

Replace transdermal analgesic patches every 72 hours.

Monitor client for break-through pain.

Answer and Explanation

The Correct Answer is A

Choice A reason: Administering analgesics on a fixed and continuous schedule is the most important intervention that the nurse should include in this client’s plan of care, because it can provide consistent and adequate pain relief for the client with metastatic cancer, who is likely to have chronic and severe pain. The nurse should follow the principles of cancer pain management, such as using the WHO analgesic ladder, titrating the dose according to the pain intensity, and using a multimodal approach that combines opioids, non-opioids, and adjuvants.

Choice B reason: Frequently evaluating the client’s pain is an important intervention that the nurse should include in this client’s plan of care, but it is not the most important one. Evaluating the client’s pain can help the nurse to assess the effectiveness of the analgesics, identify the characteristics and causes of the pain, and adjust the pain management plan accordingly. However, evaluating the pain alone is not enough to provide pain relief, and the nurse should also implement the appropriate interventions based on the evaluation.

Choice C reason: Replacing transdermal analgesic patches every 72 hours is not a relevant intervention that the nurse should include in this client’s plan of care, because it is not applicable to the client’s situation. Transdermal analgesic patches are a form of opioid delivery that can provide long-lasting pain relief, but they are not suitable for acute or breakthrough pain, and they have a delayed onset of action. The client in this scenario is receiving IV analgesics, which have a faster onset and shorter duration of action, and are more appropriate for acute or breakthrough pain.

Choice D reason: Monitoring the client for break-through pain is an important intervention that the nurse should include in this client’s plan of care, but it is not the most important one. Break-through pain is a sudden and transient increase in pain that occurs despite the use of regular analgesics, and it can be caused by various factors, such as movement, infection, or tumor progression. The nurse should monitor the client for break-through pain and administer rescue doses of analgesics as needed. However, monitoring the client for break-through pain is not enough to prevent or treat the pain, and the nurse should also administer analgesics on a fixed and continuous schedule to maintain a steady level of pain relief.

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Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason: Teaching the client breathing exercises can help improve lung function, reduce mucus accumulation, and prevent atelectasis and pneumonia. Breathing exercises can include pursed-lip breathing, diaphragmatic breathing, and coughing techniques.

Choice B reason: Establishing a regular bladder routine is not directly related to pulmonary complications. However, it can help prevent urinary tract infections, bladder distension, and incontinence, which are common problems for clients with ALS.

Choice C reason: Performing chest physiotherapy can help mobilize secretions, improve ventilation, and prevent respiratory infections. Chest physiotherapy can include percussion, vibration, and postural drainage.

Choice D reason: Encouraging use of incentive spirometer can help increase lung expansion, improve oxygenation, and prevent alveolar collapse. Incentive spirometer is a device that measures the amount of air the client can inhale and exhale.

Choice E reason: Initiating passive range of motion exercises can help maintain joint mobility, prevent contractures, and improve circulation. Passive range of motion exercises are performed by the nurse or a caregiver who moves the client's limbs through their full range of motion.

A. Begin a weight loss program. B. Drink 1 to 2 glasses of wine at bedtime. C. Take sedatives prior to sleep. D. Sleep with the head of the bed flat.

Correct Answer is A

Explanation

Choice A reason: Beginning a weight loss program can help reduce the severity of OSA, which is a condition that causes repeated episodes of breathing cessation during sleep due to upper airway obstruction. Excess weight can contribute to OSA by increasing the fat deposits around the neck and throat, which can narrow the airway and make it more prone to collapse. Losing weight can help improve the airflow and reduce the need for CPAP therapy.

Choice B reason: Drinking 1 to 2 glasses of wine at bedtime can worsen OSA, which is a condition that requires adequate oxygenation and ventilation during sleep. Alcohol can relax the muscles of the throat and tongue, which can increase the risk of airway obstruction and apnea. Alcohol can also disrupt the sleep cycle and quality, which can affect the overall health and well-being of the client.

Choice C reason: Taking sedatives prior to sleep can also worsen OSA, which is a condition that requires alertness and arousal during sleep to resume breathing after an apneic episode. Sedatives can depress the central nervous system and the respiratory drive, which can reduce the responsiveness and the ability to overcome the airway obstruction. Sedatives can also have adverse effects, such as drowsiness, confusion, and dependency.

Choice D reason: Sleeping with the head of the bed flat can also worsen OSA, which is a condition that requires optimal positioning and alignment during sleep to prevent the airway obstruction. Sleeping with the head of the bed flat can cause the tongue and the soft palate to fall back and block the airway, especially when lying on the back. Sleeping with the head of the bed elevated can help open the airway and reduce the snoring and the apnea.

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A client with metastatic cancer reports a pain level of 10 on a pain scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which intervention is most important for the nurse to include in this client’s plan of care?

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Naxlex Comprehensive Predictor Exams

To reduce the risk for pulmonary complications for a client with Amyotrophic Lateral Sclerosis (ALS), which interventions should the nurse implement? (Select all that apply)

Correct Answer is ["A","C","D","E"]

Explanation

A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. The client asks the nurse for an alternative way to manage sleep apnea. Which recommendation should the nurse provide?

Correct Answer is A

Explanation

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