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

Administer analgesics on a fixed and continuous schedule.

Frequently evaluate the client’s pain.

Replace transdermal analgesic patches every 72 hours.

Monitor client for break-through pain.

Answer and Explanation

The Correct Answer is A

Choice A reason: Administering analgesics on a fixed and continuous schedule is the most important intervention that the nurse should include in this client’s plan of care, because it can provide consistent and adequate pain relief for the client with metastatic cancer, who is likely to have chronic and severe pain. The nurse should follow the principles of cancer pain management, such as using the WHO analgesic ladder, titrating the dose according to the pain intensity, and using a multimodal approach that combines opioids, non-opioids, and adjuvants.

Choice B reason: Frequently evaluating the client’s pain is an important intervention that the nurse should include in this client’s plan of care, but it is not the most important one. Evaluating the client’s pain can help the nurse to assess the effectiveness of the analgesics, identify the characteristics and causes of the pain, and adjust the pain management plan accordingly. However, evaluating the pain alone is not enough to provide pain relief, and the nurse should also implement the appropriate interventions based on the evaluation.

Choice C reason: Replacing transdermal analgesic patches every 72 hours is not a relevant intervention that the nurse should include in this client’s plan of care, because it is not applicable to the client’s situation. Transdermal analgesic patches are a form of opioid delivery that can provide long-lasting pain relief, but they are not suitable for acute or breakthrough pain, and they have a delayed onset of action. The client in this scenario is receiving IV analgesics, which have a faster onset and shorter duration of action, and are more appropriate for acute or breakthrough pain.

Choice D reason: Monitoring the client for break-through pain is an important intervention that the nurse should include in this client’s plan of care, but it is not the most important one. Break-through pain is a sudden and transient increase in pain that occurs despite the use of regular analgesics, and it can be caused by various factors, such as movement, infection, or tumor progression. The nurse should monitor the client for break-through pain and administer rescue doses of analgesics as needed. However, monitoring the client for break-through pain is not enough to prevent or treat the pain, and the nurse should also administer analgesics on a fixed and continuous schedule to maintain a steady level of pain relief.

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Correct Answer is A

Explanation

Choice A reason: Varicella is another name for chickenpox, which is caused by the varicella-zoster virus. Herpes zoster, also known as shingles, is a reactivation of the same virus that causes a painful rash along a nerve pathway. People who have had chickenpox are at risk of developing shingles later in life, especially if their immune system is weakened. Asking the client if everyone at home has already had varicella can help the nurse determine the risk of transmission and the need for isolation precautions.

Choice B reason: Antifungal creams are not effective for herpes zoster, which is caused by a virus, not a fungus. Antifungal creams are used to treat fungal infections, such as athlete's foot, ringworm, or candidiasis. Asking the client if the antifungal creams have been effective is not relevant to the condition and can indicate a lack of knowledge or a misdiagnosis.

Choice C reason: Dry patches on the feet and hands are not typical signs of herpes zoster, which usually causes a blistering rash along a nerve pathway. Dry patches on the feet and hands can be caused by other conditions, such as eczema, psoriasis, or diabetes. Asking the client if they have any dry patches on their feet and hands is not helpful to assess the condition and can divert the attention from the main problem.

Choice D reason: Sharing combs and brushes is not a common mode of transmission for herpes zoster, which is spread by direct contact with the fluid from the blisters. Sharing combs and brushes can transmit other infections, such as lice, scabies, or impetigo. Asking the client if their family members share combs and brushes is not pertinent to the condition and can imply a poor hygiene or a stigma.

A. Begin a weight loss program. B. Drink 1 to 2 glasses of wine at bedtime. C. Take sedatives prior to sleep. D. Sleep with the head of the bed flat.

Correct Answer is A

Explanation

Choice A reason: Beginning a weight loss program can help reduce the severity of OSA, which is a condition that causes repeated episodes of breathing cessation during sleep due to upper airway obstruction. Excess weight can contribute to OSA by increasing the fat deposits around the neck and throat, which can narrow the airway and make it more prone to collapse. Losing weight can help improve the airflow and reduce the need for CPAP therapy.

Choice B reason: Drinking 1 to 2 glasses of wine at bedtime can worsen OSA, which is a condition that requires adequate oxygenation and ventilation during sleep. Alcohol can relax the muscles of the throat and tongue, which can increase the risk of airway obstruction and apnea. Alcohol can also disrupt the sleep cycle and quality, which can affect the overall health and well-being of the client.

Choice C reason: Taking sedatives prior to sleep can also worsen OSA, which is a condition that requires alertness and arousal during sleep to resume breathing after an apneic episode. Sedatives can depress the central nervous system and the respiratory drive, which can reduce the responsiveness and the ability to overcome the airway obstruction. Sedatives can also have adverse effects, such as drowsiness, confusion, and dependency.

Choice D reason: Sleeping with the head of the bed flat can also worsen OSA, which is a condition that requires optimal positioning and alignment during sleep to prevent the airway obstruction. Sleeping with the head of the bed flat can cause the tongue and the soft palate to fall back and block the airway, especially when lying on the back. Sleeping with the head of the bed elevated can help open the airway and reduce the snoring and the apnea.

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A client with metastatic cancer reports a pain level of 10 on a pain scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. 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 is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?

Correct Answer is A

Explanation

A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. The client asks the nurse for an alternative way to manage sleep apnea. Which recommendation should the nurse provide?

Correct Answer is A

Explanation

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