A hospice nurse is caring for a patient who has terminal cancer and is receiving hospice care for stage 4 metastatic breast cancer.
The patient experiences excruciating pain and is scheduled for morphine 10mg IM every 6 hours. The patient is sleeping, and the medication is due.

What action should the nurse take?

Hold the pain medication until the patient wakes up.

The patient should be given the scheduled pain medication.

Call the family and ask if the patient would like to be woken up to have their pain medication.

The patient has become addicted to the medication and is sleeping the last dose off.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Holding the pain medication until the patient wakes up is not the best choice. Pain can disrupt sleep, and it’s important to keep the patient as comfortable as possible. If the patient is sleeping, it may be because the pain is well-controlled, and delaying the medication could lead to a return of pain.
Choice B rationale
The patient should be given the scheduled pain medication. This is the best choice because it ensures that the patient’s pain is managed effectively. Even if the patient is sleeping, the medication should be given to prevent the pain from returning.
Choice C rationale
Calling the family and asking if the patient would like to be woken up to have their pain medication is not the best choice. The nurse should make this decision based on the patient’s pain level and the medication schedule, not on the family’s preferences.
Choice D rationale
The statement that the patient has become addicted to the medication and is sleeping the last dose off is not accurate. Addiction is a complex condition characterized by compulsive drug use despite harmful consequences. In this case, the patient is receiving the medication for a legitimate medical reason, and there is no indication of addiction.

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Correct Answer is C

Explanation

Choice A rationale
Minimal assistance implies that the patient needs some help but can do most of the task on their own. In this case, the patient is able to stand up from a seated position using a cane for support, which suggests that they do not need assistance.
Choice B rationale
Moderate assistance implies that the patient needs more help to perform the task. The patient in the scenario is able to perform the task independently with the help of a cane.
Choice C rationale
No assistance means that the patient can perform the task independently. This is the most fitting answer because the patient is able to stand up from a seated position using a cane for support.
Choice D rationale
Maximum assistance implies that the patient is unable to perform the task without substantial help. This does not apply to the patient in the scenario as they are able to stand up independently with the help of a cane.

A. The patient will increase attendance at community social activities. B. The patient will receive medication to minimize episodes of breakthrough pain. C. The patient will experience a weight gain of one to two pounds per week. D. The patient will verbalize an understanding of the mode of disease transmission.

Correct Answer is B

Explanation

Choice A rationale
Increasing attendance at community social activities may not be a realistic goal for a patient in hospice care with Stage 4 breast cancer. The patient’s physical condition and energy levels may limit their ability to participate in such activities.
Choice B rationale
Receiving medication to minimize episodes of breakthrough pain is a realistic and important goal for a patient in hospice care. Effective pain management is a key aspect of end-of-life care.
Choice C rationale
Experiencing a weight gain of one to two pounds per week may not be a realistic goal for a patient in hospice care with Stage 4 breast cancer. Patients at this stage of illness often experience weight loss, not gain.
Choice D rationale
Verbalizing an understanding of the mode of disease transmission may not be a relevant goal for a patient in hospice care with Stage 4 breast cancer. The focus of care at this stage is typically on comfort and quality of life, rather than disease education.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is conducting a mobility assessment on a patient. The patient can stand up from a seated position using a cane for support. Which of the following activity levels should the nurse assign to the patient?

Correct Answer is C

Explanation

A nurse is setting goals for a patient who has Stage 4 Breast cancer, is in hospice care, and is at the end of life. Which of the following are realistic goals?

Correct Answer is B

Explanation

The patient with glaucoma is usually started on the lowest dose of medication. Which of the following is the preferred initial ophthalmic medication?

In the context of outpatient care for a client diagnosed with Bell’s palsy, which of the following statements, if made by the client, would indicate the need for further education?

A nurse is teaching a class about stress. The nurse should include that which of the following is an example of chronic stress?

A nurse is teaching a group of older adults about risk factors for developing a stroke. Which non-modifiable risk factors should the nurse include in the teaching?

A nurse is educating a newly licensed nurse about informed consent. Which of the following should be included as a nurse’s responsibility in this process?

A client with trigeminal neuralgia has been given suggestions to minimize episodes of pain. Which statement, if made by the client, would indicate the need for further teaching?

A nurse is teaching a class about sources of stress. The nurse should include that which of the following is an example of a physiological stressor?

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