A nurse in a long-term care facility is reinforcing teaching about pain control with a client who has terminal cancer. Which of the following information should the nurse include?
Analgesia should be used around the clock to promote pain control.
Pain patches are applied each morning and removed at bedtime.
We will use intramuscular medications to control your pain.
A medication dose must be decreased if you develop tolerance.
The Correct Answer is A
Choice A reason: Using analgesia around the clock is an appropriate action. The nurse should follow the principle of prevention rather than rescue when managing pain for a client who has terminal cancer. The nurse should administer analgesics on a regular schedule to maintain a steady level of pain relief and prevent breakthrough pain.
Choice B reason: Applying pain patches each morning and removing them at bedtime is not an appropriate action. The nurse should follow the manufacturer's instructions for applying and removing pain patches. Some patches are designed to be worn for 24 hours, while others are worn for 72 hours. Removing the patches too soon can cause inadequate pain control and withdrawal symptoms.
Choice C reason: Using intramuscular medications to control pain is not an appropriate action. The nurse should avoid using intramuscular route for administering analgesics to a client who has terminal cancer. Intramuscular injections are painful, unreliable, and increase the risk of infection and bleeding. The nurse should use oral, transdermal, or subcutaneous routes whenever possible.
Choice D reason: Decreasing a medication dose if the client develops tolerance is not an appropriate action. The nurse should understand that tolerance is a normal physiological response to long-term opioid use and does not indicate addiction or abuse. The nurse should adjust the medication dose according to the client's level of pain and response to treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: This is incorrect because placing the client in the Sims' position is not necessary for a colposcopy. The nurse should place the client in the lithotomy position, which allows better visualization of the cervix and vagina.
Choice B: This is incorrect because inserting a tampon following the procedure can interfere with healing and increase the risk of infection. The nurse should instruct the client to avoid using tampons, douches, or vaginal creams for at least a week after the procedure.
Choice C: This is correct because instructing the client to avoid sexual intercourse until the cervix is healed can prevent bleeding, infection, and trauma to the cervix. The nurse should advise the client to abstain from sexual activity for at least a week or until advised by the provider.
Choice D: This is incorrect because reinforcing teaching that the procedure involves dilation of the cervix can cause anxiety and discomfort for the client. The nurse should explain that the procedure does not require dilation of the cervix, but rather involves applying a speculum and using a microscope to examine the cervix and take tissue samples if needed.
Correct Answer is B
Explanation
Choice A: This is incorrect because client status unchanged throughout shift is too vague and does not provide specific details about the client's condition and progress. The nurse should document any changes or interventions that occurred during the shift, such as vital signs, pain level, activity, and drainage.
Choice B: This is correct because abdominal wound dry, without redness is a clear and objective description of the client's wound appearance and healing. The nurse should document any signs of infection or complications, such as redness, swelling, warmth, or purulent drainage.
Choice C: This is incorrect because client received an adequate amount of fluid is too general and does not indicate the exact amount and type of fluid that the client received. The nurse should document the intake and output of the client, including any IV fluids, oral fluids, urine, stool, and drainage.
Choice D: This is incorrect because incision healing well is too subjective and does not reflect the actual assessment of the incision site. The nurse should document the size, color, and condition of the incision, as well as any sutures or staples.
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