Patient Data

Exhibits

Which intervention should the nurse prioritize for this client?

Administer pain medication as prescribed.

Provide emotional support to the family.

Assist with daily activities.

Monitor vital signs regularly.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Administering pain medication as prescribed is the priority intervention for a client receiving hospice care with significant pain and discomfort. Effective pain management is essential to ensure the client’s comfort and quality of life. Pain relief is a primary goal in hospice care, and regular administration of pain medication helps manage symptoms and improve the client’s overall well-being.

Choice B rationale

Providing emotional support to the family is important in hospice care, as families often need assistance coping with the emotional challenges of caring for a loved one with a terminal illness. However, the priority intervention is to manage the client’s pain and discomfort effectively.

Choice C rationale

Assisting with daily activities is necessary for clients with limited mobility, but it is not the primary intervention. Ensuring the client’s comfort and pain relief takes precedence, as it directly impacts their quality of life.

Choice D rationale

Monitoring vital signs regularly is part of the overall care plan, but it is not the priority intervention. The focus should be on managing the client’s pain and discomfort to provide the best possible quality of life in hospice care.

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Correct Answer is D

Explanation

Choice A rationale

Positioning the head with the chin tilted slightly downward is an appropriate action when feeding a client with a CVA. This position helps prevent aspiration by closing the airway and directing food away from the trachea.

Choice B rationale

Allowing 30 minutes of rest before feeding is an appropriate action. Resting before feeding can help improve digestion and reduce the risk of aspiration by ensuring the client is alert and responsive during feeding.

Choice C rationale

Placing food on the unaffected side of the mouth is an appropriate action when feeding a client with a CVA. This technique helps the client manage food more effectively and reduces the risk of aspiration.

Choice D rationale

Raising the head of the bed to 60 degrees is not sufficient to prevent aspiration. The head of the bed should be elevated 45 to 90 degrees to ensure proper positioning and reduce the risk of aspiration. Therefore, if the UAP raises the head of the bed to only 60 degrees, it indicates the need for additional teaching.

A. Place the vial with the remainder of the medication into a locked drawer. B. Withdraw the medication into a syringe and label it with the client’s name. C. Ask another nurse to witness the medication being discarded. D. Throw the vial into the trash in the presence of another nurse. E. Throw the vial into the trash in the presence of another nurse.

Correct Answer is C

Explanation

Choice A rationale

Placing the vial with the remainder of the medication into a locked drawer is not appropriate because it does not ensure proper documentation and accountability for the remaining medication. Controlled substances require strict documentation and disposal procedures.

Choice B rationale

Withdrawing the medication into a syringe and labeling it with the client’s name is not necessary and can lead to errors or contamination. The medication should not be stored for future use in this manner.

Choice C rationale

Asking another nurse to witness the medication being discarded is the correct action. This ensures proper documentation, accountability, and compliance with regulations for the disposal of unused or remaining medications, especially controlled substances.

Choice D rationale

Throwing the vial into the trash in the presence of another nurse is not appropriate. It does not ensure proper documentation, accountability, or safe disposal of the remaining medication.

Controlled substances require specific disposal procedures to prevent misuse or diversion.

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Patient Data Exhibits Which intervention should the nurse prioritize for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

Correct Answer is D

Explanation

The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL vial. Which action should the nurse perform with the remainder of the medication?

Correct Answer is C

Explanation

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Patient Data

Exhibits

Which intervention should the nurse prioritize for this client?