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

Answer and Explanation

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.

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Correct Answer is D

Explanation

a. While limited social support is important to address for a successful discharge plan, it may not be as urgent as addressing issues directly related to the client's recovery from surgery.
b. Decreased self-esteem is a significant concern but may not directly impact the client's immediate postoperative recovery and discharge plan.
c. Inadequate food supply is important to address for the client's overall well-being but may not be as urgent as addressing issues directly related to the client's recovery from surgery.
d. Low pain tolerance can significantly affect the client's recovery process and may require immediate attention to ensure adequate pain management postoperatively.

A. Involve the client’s partner to assist with the teaching session B. Incorporate gestures and hand signals when presenting information C. Validate understanding by interpreting the client’s body language D. Provide an interpreter when obtaining consent for the client

Correct Answer is D

Explanation

a. Involving the client's partner may be helpful for additional support, but it does not ensure accurate communication if the partner also does not speak the same language as the client.
b. While incorporating gestures and hand signals can be useful, they may not fully convey complex medical information and may lead to misunderstandings.
c. Interpreting the client's body language can provide some insight into their understanding, but it may not accurately represent their comprehension of the information.
d. Providing an interpreter ensures accurate communication and understanding between the nurse and the client, promoting effective teaching and informed decision-making.

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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?

Nursing Test Bank

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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?