A hospice nurse is caring for a client who has a terminal illness and reports severe pain. After the nurse administers the prescribed opioid and benzodiazepine, the client becomes somnolent and difficult to arouse. Which of the following actions should the nurse take?

Withhold the benzodiazepine but continue the opioid.

Administer the benzodiazepine but withhold the opioid.

Continue the medication dosages that relieve the client's pain.

Contact the provider about replacing the opioid with an NSAID.

Answer and Explanation

The Correct Answer is B

Being difficult to arouse may be and indicator of respiratory depression which is a common side effect of opioid use. This is more common when given in high doses. Although benzodiazepines could cause respiratory depression, the risk is lower.

A. opioid is more likely to be the cause of respiratory depression

C. continuing the medications despite the increased risk of respiratory depression is unethical

D. An NSAID is unlikely to provide optimal analgesia which is a key goal in end of life care,

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Correct Answer is A

Explanation

The nurse should prioritize care based on the ABCs of basic life support. The client with neck injury likely has airway obstruction which poses immediate risk of death and should, therefore, be addressed first.

B. Client is exhibiting features of a psychiatric disorder which can be addressed later.

C. Client has issues with inadequate breathing which comes second after airway.

D. Client is likely to have circulatory issues due to dehydration secondary to skin losses.

A. A client who has a raised red skin rash on his arms, neck, and face B. A client who has active bleeding from a puncture wound of the left groin area C. A client who reports right-sided flank pain and is diaphoretic D. A client who reports shortness of breath and left neck and shoulder pain

Correct Answer is A

Explanation

A. The client with active bleeding from a puncture wound in the groin is the highest priority because of the risk of severe blood loss, which can lead to hypovolemic shock. The nurse should quickly apply pressure to the wound, assess the extent of the bleeding, and prepare for emergency interventions.

B Active bleeding is part of crculation in the ABCs that comes after airway and breathing

C. Client could be having a kidney stone which is not a priority

D.These symptoms could indicate a pulmonary embolism or heart attack, but they may not be as immediately life-threatening as active bleeding.

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A hospice nurse is caring for a client who has a terminal illness and reports severe pain. After the nurse administers the prescribed opioid and benzodiazepine, the client becomes somnolent and difficult to arouse. Which of the following actions should the nurse take?

Nursing Test Bank

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