A female client who is receiving hospice care in her home expresses fear that dying will be painful. Which action should the nurse take first?

Include caregiver in discussion of pain relief strategies.

Encourage the client to talk about her fear related to pain.

Explain that analgesics will be given whenever needed.

Provide therapeutic touch along with comfort and support.

Answer and Explanation

The Correct Answer is B

A. Including the caregiver in discussions about pain relief strategies is important, but addressing the client’s immediate concerns and fears should come first.
B. Encouraging the client to talk about her fear related to pain allows the nurse to understand her specific concerns and provide personalized reassurance and support. Addressing the client’s emotional needs is crucial in hospice care.
C. Explaining that analgesics will be given as needed is important for reassurance but may not fully address the client’s fear or allow for an open discussion about her concerns.
D. Providing therapeutic touch and comfort is supportive but does not directly address the client’s fear. Engaging in a conversation about her specific fears allows for more targeted and effective reassurance.

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Correct Answer is A

Explanation

A. Reducing the amount of pressure applied is the appropriate next step because excessive pressure can occlude the pulse, making it difficult to feel. Lightening the pressure may help the nurse detect the pulse.
B. Palpating the posterior tibial pulse (below the medial malleolus) is another option if the dorsalis pedis pulse is not palpable, but it should be attempted only after ensuring that proper technique was used to feel the dorsalis pedis pulse.
C. Using a Doppler stethoscope is a good option if the pulse remains non-palpable after proper technique has been used. However, it is not the immediate next step.
D. Documenting that the dorsalis pedis pulse is not palpable should be done after all appropriate steps, including adjusting the pressure and possibly using a Doppler, have been attempted.

A. Ask the UAP to offer a backrub to the client. B. Reassess the client and the level of pain. C. Tell the client the medication needs more time to work. D. Encourage the client to focus on taking deep breaths.

Correct Answer is B

Explanation

A. Asking a UAP to offer a backrub is not appropriate if the pain assessment indicates that the current pain management strategy is insufficient. The nurse needs to reassess the pain to determine the effectiveness of the medication and whether additional interventions are needed.
B. Reassessing the client and the level of pain is essential to evaluate the effectiveness of the morphine sulfate administered and to guide further pain management decisions. This step is crucial for understanding the client's current pain status and determining the next steps in pain management.
C. Telling the client that the medication needs more time to work does not address the client's immediate concern or pain relief. Reassessing pain and potentially adjusting the treatment plan is more appropriate.
D. Encouraging deep breathing may help with pain management but does not address the need for further assessment of the pain level or potential adjustment in medication. Reassessing pain is the priority.

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A female client who is receiving hospice care in her home expresses fear that dying will be painful. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To assess a client's dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes, but does not feel a pulsation. Which action should the nurse take next?

Correct Answer is A

Explanation

A client is requesting medicine for pain 30 minutes after receiving morphine sulfate 5 mg intravenously. Which intervention should the nurse implement next?

Correct Answer is B

Explanation

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