Patient Data
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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Starting to collect the specimen with the next void is the correct action. The 24-hour urine collection for creatinine clearance should start with an empty bladder. The first urine of the day is discarded, and the time is noted.
Choice B rationale
Beginning the collection the next day is unnecessary and would delay the process. It is important to start the collection as soon as possible to avoid further delays.
Choice C rationale
Observing the sample for sediment is not relevant to the collection process. The focus should be on starting the collection with the next void.
Choice D rationale
Emptying the sample into the 24-hour container is incorrect because the first urine sample should be discarded to ensure accurate results.
Correct Answer is A
Explanation
Choice A rationale
Injecting in the abdominal area at least 2 inches (5.1 cm) from the umbilicus is the correct technique for subcutaneous heparin injections. This reduces the risk of injury to blood vessels and nerves and ensures consistent absorption of the medication.
Choice B rationale
Rotating injections between the abdomen and gluteal areas is not recommended for low molecular weight heparin (LMWH) injections. The abdomen is the preferred site for consistent absorption.
Choice C rationale
Massaging the injection site to increase absorption is not recommended for LMWH injections. Massaging can cause bruising and affect the absorption of the medication.
Choice D rationale
Expelling the air in the prefilled syringe prior to injection is not recommended for LMWH injections. The air bubble helps ensure the entire dose is administered and prevents medication from leaking out.
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