A hospice nurse is caring for a client who has 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?
Continue the medication dosages that relieve the client’s pain
Contact the provider about replacing the opioid with an NSAID
Administer the benzodiazepine but withhold the opioid
Withhold the benzodiazepine but continue the opioid
The Correct Answer is D
a. Continuing both medications may exacerbate the somnolence and difficulty arousing experienced by the client. It's essential to address the adverse effects promptly.
b. NSAIDs are not typically the first choice for severe pain management in terminal illness, especially when opioids are already prescribed. Moreover, replacing the opioid with an NSAID may not adequately address the pain.
c. Administering the benzodiazepine alongside the opioid may further potentiate the sedative effects and worsen the client's condition.
d. This is the most appropriate action. Withholding the benzodiazepine can help mitigate the sedation while continuing the opioid ensures ongoing pain relief for the client's comfort without introducing additional sedating medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. This is incorrect because a health care proxy doesn't necessarily have to be a family member. It can be any person chosen by the individual.
b. This is the correct response because it accurately describes the role of a health care proxy, which is to make decisions for the individual when they are unable to do so themselves.
c. This is incorrect because appointing a health care proxy is not contingent upon undergoing an invasive procedure.
d. This is incorrect because the involvement of an attorney is not necessary to appoint a health care proxy.
Correct Answer is B
Explanation
a. While alerting the infection control department is important, directly addressing the issue with the involved personnel should be the initial action.
b. Discussing the issue with the assistive personnel (AP) allows for immediate clarification of the protocol and provides an opportunity to correct the behavior.
c. Reinforcing facility protocols at a staff meeting may be necessary but should not be the first step when immediate action is required.
d. Notifying the unit manager is important, but addressing the issue with the AP directly is the first step in resolving the situation and preventing future occurrences.
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