A client with metastatic cancer reports a pain level of 10 on a 0 to 10 scale. Twenty minutes after the nurse administers an IV analgesic, the client states, "No pain relief yet." Which intervention is most important for the nurse to include in this client's plan of care?

Replace transdermal analgesic patches every 72 hours.

Administer analgesics on a fixed and continuous schedule.

Monitor the client for breakthrough pain.

Frequently evaluate the client's pain.

Answer and Explanation

The Correct Answer is B

Choice A reason: Replacing patches is important but not as immediately effective as managing pain on a continuous basis.

Choice B reason:

The correct answer is b) because administering analgesics on a fixed and continuous schedule helps manage chronic pain more effectively than as-needed dosing.

Choice C reason: Monitoring for breakthrough pain is important but does not address the need for continuous pain management.

Choice D reason: Frequent evaluation is essential but should be part of a broader pain management strategy.

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Correct Answer is B

Explanation

Choice A reason: Measuring intake and output is important but not the immediate action needed to address blood clots.

Choice B reason:

The correct answer is b) because increasing the flow of the bladder irrigation can help to flush out blood clots and maintain catheter patency.

Choice C reason: Providing additional oral fluid intake is helpful but not the initial action to clear clots.

Choice D reason: Administering an antispasmodic agent can relieve bladder spasms but does not address the clots directly.

A. Assess pulses with a vascular doppler. B. Evaluate edema for pitting. C. Wrap the feet with warmed blankets. D. Elevate extremities on pillows.

Correct Answer is A

Explanation

Choice A reason:

The correct answer is a) because using a vascular doppler to assess pulses is critical for determining blood flow and identifying potential complications.

Choice B reason: Evaluating edema is important but not the immediate priority.

Choice C reason: Wrapping feet with blankets does not address the underlying issue of blood flow.

Choice D reason: Elevating extremities can help with edema but is not the first action to assess pulses.

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A client with metastatic cancer reports a pain level of 10 on a 0 to 10 scale. Twenty minutes after the nurse administers an IV analgesic, the client states, "No pain relief yet." Which intervention is most important for the nurse to include in this client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which is the best initial nursing action?

Correct Answer is B

Explanation

Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?

Correct Answer is A

Explanation

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