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?

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.

Withhold the benzodiazepine but continue the opioid.

Answer and Explanation

The Correct Answer is B

A.   Withholding the opioid may lead to inadequate pain relief, which isn't the best approach, especially in a terminally ill patient experiencing severe pain.
B.   Continuing the medication dosages that relieve pain is important for the client's comfort, even if it causes somnolence.
C.   Contacting the provider to consider an NSAID might be an option, but immediate relief should not be compromised while awaiting a change in medication.
D.   Withholding the benzodiazepine might be considered if the sedation is excessive, but prioritizing pain relief is crucial in end-of-life care unless there are severe adverse effects.

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Correct Answer is D

Explanation

A. A client with gestational diabetes receiving biweekly nonstress tests typically requires monitoring and assessment that align more closely with obstetric nursing knowledge and skills rather than medical-surgical nursing.
B. A multigravida client with preeclampsia receiving misoprostol for induction of labor needs specialized obstetric care due to the complexity of the condition and the induction process.
C. A client at 32 weeks of gestation with premature rupture of membranes would require obstetric care expertise for monitoring and management.
D. A primigravida client 1 day postoperative following a Cesarean section with a patient- controlled analgesia (PCA) pump requires specialized postoperative obstetric care,
making this assignment suitable for the RN who floated from a medical-surgical unit due to their experience with postoperative care and pain management.

A. Obtain telephone consent from the facility administrator before the surgery. B. Delay the surgery until the nurse can obtain informed consent. C. Ask the anesthesiologist to sign the consent. D. Transport the client to the operating room without verifying informed consent.

Correct Answer is D

Explanation

A. Telephone consent from the facility administrator might not be sufficient for the specific informed consent required for surgery on an unconscious client.
B. Delaying surgery to ensure proper informed consent is obtained is not appropriate since the client is in a critical condition and delaying surgery might cause death.
C. Asking the anesthesiologist to sign the consent is not appropriate as the responsibility for obtaining informed consent typically lies with the surgeon or responsible provider.
D. Transporting the client to the operating room without informed consent is appropriate in emergency situations where the client is unconscious.

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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

Naxlex Comprehensive Predictor Exams

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