In-home hospice care is arranged for a client with stage 4 lung cancer. While the palliative care nurse is arranging for discharge, the client verbalizes concerns about pain. Which action should the nurse implement?

Recommend asking the healthcare professional for a patient-controlled analgesia (PCA) pump.

Explain the respiratory problems that can occur with morphine use.

Teach family how to evaluate the effectiveness of analgesics.

Provide client with a schedule of around-the-clock prescribed analgesic use.

Answer and Explanation

The Correct Answer is D

A. A PCA pump could be considered, but the immediate action should be ensuring the client understands and follows the prescribed pain management regimen.
B. While explaining potential side effects like respiratory depression is important, this action may increase anxiety about pain management rather than address the client's current concern.
C. Teaching the family how to evaluate the effectiveness of analgesics is important but secondary to ensuring the client is consistently receiving pain relief.
D. Providing the client with a schedule of around-the-clock prescribed analgesic use is crucial in managing pain effectively in hospice care. Consistent pain management, rather than waiting for pain to become severe, is a key principle in palliative care to ensure comfort.

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Correct Answer is []

Explanation

Acute pain: The client’s symptoms, such as moaning, facial grimacing, and muscle spasms in the right leg, suggest they are experiencing acute pain. This condition is consistent with the sudden onset of pain and physical reactions.
Request prescription for pain medication: This action addresses the client’s immediate pain needs, helping to alleviate discomfort and improve overall well-being.
Request antispasmodic medication: The muscle spasms observed indicate that an antispasmodic may help reduce the muscle tension and associated pain, providing relief from the spasms.
Response to pain medications: Monitoring the client's response to the prescribed pain medication will help determine the effectiveness of the intervention and whether further adjustments are needed.
Severity of muscle spasms: Assessing the severity of muscle spasms will help evaluate the impact of the antispasmodic treatment and provide insight into the client’s progress in managing the pain.

A. Raise the four side rails on the bed. B. Close the client's room door. C. Orient the client to the surroundings. D. Secure a bed alarm on the mattress. E. Escort the client back to her room.

Correct Answer is ["C","D","E"]

Explanation

A. Raising the four side rails on the bed can be considered a form of restraint and might increase the risk of injury if the client attempts to climb over them. It is not recommended unless necessary and in accordance with facility policies.
B. Closing the client's room door could increase the client's confusion and sense of isolation, making it harder for the staff to monitor the client’s safety.
C. Orienting the client to the surroundings is essential in reducing confusion and preventing further wandering. It helps the client feel more secure and less disoriented.
D. Securing a bed alarm on the mattress is a proactive safety measure that can alert the staff if the client attempts to leave the bed again, thus preventing potential harm.
E. Escorting the client back to her room ensures immediate safety and provides an opportunity to assess the client's condition and needs in a controlled environment.

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In-home hospice care is arranged for a client with stage 4 lung cancer. While the palliative care nurse is arranging for discharge, the client verbalizes concerns about pain. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

The nurse finds a confused client wandering in the hallway during the night. Which actions should the nurse implement? (Select all that apply)

Correct Answer is ["C","D","E"]

Explanation

The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?

The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?

The nurse is teaching a client about how to use crutches. Which action performed by the client demonstrates to the nurse a correct understanding of how to use the crutches?

The nurse assesses that a client who is disoriented drank eight glasses of water in two hours and is continuing to drink excessive amounts of water. Because the nurse is concerned about water intoxication, which laboratory value should the nurse monitor?

An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. What action should the nurse take first?

Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning?