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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Initiating life-saving measures such as a rapid response call would not be appropriate in this context. The patient is in a hospice setting, which focuses on providing comfort and quality of life for patients who are nearing the end of life, rather than aggressive life-saving interventions.
Choice B rationale
Calling the provider because these signs and symptoms are abnormal would not be the correct response. In a hospice setting, these symptoms are expected and are indicative of the natural dying process.
Choice C rationale
The statement that rapid respirations that are unusually deep and regular are curative for the patient is incorrect. Cheyne-Stokes respirations, characterized by a pattern of increasing and then decreasing depth of breath followed by a period of apnea, are often seen in patients nearing the end of life. They are not curative but are a sign of the body’s decreasing metabolic demands and changing physiology as death approaches.
Choice D rationale
The nurse understanding that these are impending signs of death and are normal is the correct response. The symptoms described, including loss of appetite, swelling of the limbs, increased sleep, Cheyne-Stokes respirations, and hallucinations, are all common in the final stages of life.
Recognizing these signs can help the nurse provide appropriate care and support to the patient and their family during this time.
Correct Answer is A
Explanation
Choice A rationale
Increased joint stiffness is a common age-related change in older adults.
Choice B rationale
Increased muscle mass is not typically an age-related change. In fact, older adults often experience a decrease in muscle mass, a condition known as sarcopenia.
Choice C rationale
Increased calcification of bones is not a typical age-related change. Older adults are more likely to experience osteoporosis, a condition characterized by a decrease in bone density.
Choice D rationale
Decreased balance is a common age-related change, but it is not the correct answer for this question.
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