A hospice nurse is caring for a client who has a terminal illness and reports severe pain. After the nurse administers the prescribed opioid and benzodiazepine, the client becomes somnolent and difficult to arouse. Which of the following actions should the nurse take?
Administer the benzodiazepine but withhold the opioid.
Continue the medication dosages that relieve the client's pain.
Contact the provider about replacing the opioid with an NSAID.
Withhold the benzodiazepine but continue the opioid.
The Correct Answer is B
A. Withholding the opioid may lead to inadequate pain relief, which isn't the best approach, especially in a terminally ill patient experiencing severe pain.
B. Continuing the medication dosages that relieve pain is important for the client's comfort, even if it causes somnolence.
C. Contacting the provider to consider an NSAID might be an option, but immediate relief should not be compromised while awaiting a change in medication.
D. Withholding the benzodiazepine might be considered if the sedation is excessive, but prioritizing pain relief is crucial in end-of-life care unless there are severe adverse effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Keeping all four side rails up on beds can increase the risk of entrapment or injury and isn't recommended as a fall prevention strategy.
B. Instituting regular rounds during the day to offer toileting helps prevent falls related to residents attempting to get to the bathroom independently.
C. Accompanying older residents during ambulation is helpful but might not be feasible at all times and for all residents.
D. Using vest restraints can lead to physical and psychological complications and is not recommended due to ethical and safety concerns.
Correct Answer is D
Explanation
A. Telephone consent from the facility administrator might not be sufficient for the specific informed consent required for surgery on an unconscious client.
B. Delaying surgery to ensure proper informed consent is obtained is not appropriate since the client is in a critical condition and delaying surgery might cause death.
C. Asking the anesthesiologist to sign the consent is not appropriate as the responsibility for obtaining informed consent typically lies with the surgeon or responsible provider.
D. Transporting the client to the operating room without informed consent is appropriate in emergency situations where the client is unconscious.
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