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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. High doses of fish oil can indeed increase the risk of bleeding, particularly because fish oil has anticoagulant properties that can interfere with blood clotting. This risk is especially significant if the client is also taking other anticoagulant or antiplatelet medications.
B. While it is true that fish can be heart-healthy due to its omega-3 fatty acids, this statement does not fully address the concerns about the safety of high doses of fish oil supplements. Eating fish in moderate amounts is beneficial, but the focus here is on the effects of large doses of fish oil supplements, not just consuming fish. The safety of high doses should be considered separately.
C. Encouraging the client to increase the dose of fish oil is not appropriate without considering potential side effects and risks. High doses of fish oil can lead to gastrointestinal symptoms like nausea, diarrhea, and indigestion.
D. Not all types of oils increase cholesterol and triglycerides. For instance, omega-3 fatty acids found in fish oil can actually help lower triglyceride levels and may have a positive effect on cholesterol levels.

A. Explain the respiratory problems that can occur with morphine use. B. Recommend asking the healthcare professional for a patient-controlled analgesia (PCA) pump. C. Provide client with a schedule of around-the-clock prescribed analgesic use. D. Teach family how to evaluate the effectiveness of analgesics.

Correct Answer is C

Explanation

A. Morphine is a potent opioid used for pain relief, but it can have side effects, including respiratory depression. While it is important to be aware of and discuss potential side effects, focusing on
respiratory problems might increase the client’s anxiety about using the medication.
B. A PCA pump allows patients to self-administer pain medication within prescribed limits, providing more control over pain management. However, PCA pumps are typically used in hospital settings and may not be practical or appropriate for home hospice care.
C. Providing a schedule for around-the-clock analgesic use is a practical and effective approach to pain management. It ensures that the client receives consistent pain relief and helps prevent the pain from becoming unmanageable.
D. Teaching the family to evaluate the effectiveness of analgesics is important for ongoing pain management. This includes recognizing signs of pain relief and potential side effects. However, this action might be more relevant once pain management is underway and requires follow-up, rather than addressing the immediate concern of managing pain effectively from the start.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A male client tells the nurse that he is taking large doses of a fish oil supplement to lower his triglyceride level. Which action should the nurse take?

Correct Answer is A

Explanation

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?

Correct Answer is C

Explanation

An older client with colorectal carcinoma receives a colostomy following a bowel resection and the nurse is reviewing written instructions about colostomy care that the client will take home after discharge. Which action should the nurse include when reviewing the instructions with the client?

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

A client who has a continuous tube feeding develops a fever and reports experiencing dyspnea. Which action should the nurse implement?

When identifying the goals to be included in a client's plan of care, the nurse should take which action?

In assisting the family of an older adult client to determine the best living environment for the client, which factor is most important for the nurse to consider?

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

An older adult client's skin feels warm and the client has a temperature of 101.2° F (38.4° C). The nurse further assesses that the client has a reddened tongue, dry mucous membranes, and inelastic skin turgor. Which serum laboratory value should the nurse monitor most closely?