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 C

Explanation

A. Applying a warm compress does not address the prevention of pressure ulcers and could potentially exacerbate skin issues. The primary focus should be on preventing further pressure.
B. Washing the area with soap and water does not effectively address the issue of pressure ulcer risk or the need for repositioning to alleviate pressure.
C. Reassessing and turning the client every 30 minutes helps prevent the development of pressure ulcers by relieving pressure on vulnerable areas, which is crucial for maintaining skin integrity.
D. Massaging the reddened area can cause further damage and is not recommended. Proper repositioning and pressure relief are the appropriate interventions.

A. Remove the coffee from the tray, advising the client that it is not included in the diet. B. Determine which member of the nursing staff brought the cup of coffee to the client. C. Remind the client that no milk or creamer can be added to the coffee. D. Consult with the dietician to learn if the client is allowed to drink coffee.

Correct Answer is C

Explanation

A. Removing the coffee might not be necessary if coffee is allowed on a clear liquid diet. The client may have been provided with the coffee based on dietary guidelines.
B. Determining which staff member brought the coffee does not address the immediate need to ensure dietary guidelines are followed.
C. On a clear liquid diet, coffee is typically allowed as long as it is consumed without milk or cream. Advising the client about this restriction ensures adherence to the diet and proper management of dietary restrictions.
D. Consulting with the dietician is important for confirming dietary guidelines but addressing the immediate situation with the client’s understanding of their diet is a more direct action.

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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?

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Naxlex Comprehensive Predictor Exams

When turning a male client who has been lying on his back for 2 hours, the nurse notes that the skin over his sacrum is very white. The client is repositioned and when the nurse reassesses the sacrum 2 hours later, the area is bright red. Which intervention should the nurse implement?

Correct Answer is C

Explanation

The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

Correct Answer is C

Explanation

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