The palliative care nurse is admitting a client who has metastatic bone cancer and is unable to eat or drink without immediate nausea and vomiting. The client is complaining of pain at 9 on a 0 to 10 pain scale, and the vital signs are: heart rate 99 beats/minute, respirations 38 breaths/minute, oxygen saturation 95%, and blood pressure 110/80 mm Hg. Which Intervention should the nurse implement?
Initiate infusion for an IV fluid bolus.
Administer an IV antiemetic.
Medicate with PRN IV narcotic.
Discourage straining on stool.
The Correct Answer is C
A. While hydration is important, it's not the most immediate concern when the client is experiencing severe pain and nausea. Addressing the pain should be the priority.
B. Antiemetics can be helpful for managing nausea and vomiting, but they may not be as effective in addressing the severe pain.
C. The client's self-reported pain level of 9 on a 0 to 10 scale indicates severe pain, which requires immediate management. IV narcotics are effective for managing severe pain and can be administered quickly to provide immediate relief. Addressing the client's pain can also help to alleviate nausea and vomiting, as pain can exacerbate these symptoms.
D. This is not relevant to the client's current symptoms of severe pain and nausea.
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Related Questions
Correct Answer is D
Explanation
A. While the use of absorbent undergarments is relevant to managing urinary incontinence, having them dry for 6 hours indicates that they are performing their function well in terms of absorbing urine. This finding does not immediately suggest a new issue that needs urgent further assessment.
B. A heel dressing saturated with serous drainage suggests that the stage II pressure ulcer on the left heel is producing a significant amount of fluid. Serous drainage is typically clear or light yellow and can indicate a wound that is still in the inflammatory phase of healing
C. Frequent requests for sleep medication can indicate issues with sleep patterns or underlying psychological stress. While it’s important to address sleep difficulties, this finding might not be as immediately critical as other concerns but warrants further assessment to address possible underlying causes and manage sleep issues appropriately.
D. Confusion about time, place, and environment in a newly admitted client is a significant finding and requires urgent further assessment. This level of confusion could be indicative of a serious issue such as delirium, which can be caused by various factors including infection, dehydration, metabolic imbalances, or a sudden change in environment.
Correct Answer is ["A","B","D","E"]
Explanation
A. This device can be used to summon help quickly in case of a fall or other emergency.
B. Grab bars provide extra support and can help prevent falls in areas where the risk is high.
C. Request that a family member move in with her might be a solution for some people but it is not always practical or desirable. It's important to consider the client's preferences and independence when making recommendations.
D. Regular exercise can help strengthen muscles and improve balance, reducing the risk of falls.
E. A home health nurse can identify potential hazards in the home and make recommendations for modifications to improve safety.
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