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 C

Explanation

Choice A reason: An apical heart rate of 100 to 110 beats/minute is not unusual after surgery, as the client may be experiencing stress, pain, or anxiety. This finding does not require immediate action by the nurse, but should be monitored and reported if it persists or worsens.

Choice B reason: Redness and edema at the incision site are expected signs of inflammation and healing after surgery. This finding does not require immediate action by the nurse, but should be assessed for signs of infection, such as pus, warmth, or foul odor.

Choice C reason: A high-pitched sound heard upon inspiration, also known as stridor, is a sign of upper airway obstruction, which can be life-threatening. This finding requires immediate action by the nurse, such as administering oxygen, suctioning, or calling for help.

Choice D reason: A pain rating of 8 on a scale of 1 to 10 indicates severe pain, which can affect the client's recovery and comfort. This finding requires prompt action by the nurse, such as administering analgesics, repositioning, or providing non-pharmacological interventions. However, this is not as urgent as choice C, which involves the client's airway.

A. Confirmation of the autoimmune disease process. B. Evidence of spread of the disease to the kidneys. C. Indication of the onset of joint degeneration. D. Representative of a decline in the client’s condition.

Correct Answer is A

Explanation

Choice A reason: Rheumatoid factor is an antibody that is produced by the immune system and can bind to normal tissues, causing inflammation and damage. Rheumatoid factor is a marker of the autoimmune disease process that underlies rheumatoid arthritis, which is a chronic condition that affects the joints and other organs. A high level of rheumatoid factor can confirm the diagnosis of rheumatoid arthritis and indicate the severity of the disease.

Choice B reason: Rheumatoid factor is not a specific indicator of kidney involvement in rheumatoid arthritis, which is a rare but possible complication of the disease. Kidney damage can occur due to inflammation of the blood vessels, medication side effects, or dehydration. Kidney function can be assessed by other laboratory tests, such as blood urea nitrogen, creatinine, and urine analysis.

Choice C reason: Rheumatoid factor is not a direct cause of joint degeneration in rheumatoid arthritis, which is a progressive condition that leads to joint deformity and disability. Joint degeneration can occur due to chronic inflammation, erosion of cartilage and bone, and formation of nodules and cysts. Joint damage can be evaluated by physical examination, x-rays, and magnetic resonance imaging.

Choice D reason: Rheumatoid factor is not a reliable predictor of the client’s condition in rheumatoid arthritis, which is a variable and unpredictable disease that can have periods of remission and exacerbation. The client’s condition can be influenced by many factors, such as age, gender, genetics, lifestyle, and treatment. The client’s condition can be monitored by clinical symptoms, functional status, and quality of life.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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