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?

Continue the medication dosages that relieve the client’s pain

Contact the provider about replacing the opioid with an NSAID

Administer the benzodiazepine but withhold the opioid

Withhold the benzodiazepine but continue the opioid

Answer and Explanation

The Correct Answer is A

A. Continue the medication dosages that relieve the client’s pain:
Opioids and benzodiazepines are commonly used for pain and anxiety management in terminally ill patients. Somnolence is an expected side effect and does not necessarily warrant withholding medication unless the client shows signs of respiratory depression.

B. Contact the provider about replacing the opioid with an NSAID: NSAIDs are not sufficient for severe pain in terminal illness. Opioids are the gold standard for palliative pain management, and switching to an NSAID would likely lead to uncontrolled pain and unnecessary suffering.

C. Administer the benzodiazepine but withhold the opioid: This would leave the client in severe pain, which is unethical in hospice care. Pain relief should not be withheld solely due to sedation.

D. Withhold the benzodiazepine but continue the opioid: Benzodiazepines are often used to relieve anxiety, dyspnea, and agitation in end-of-life care. Withholding it could cause increased distress for the client. Instead of discontinuing the medication, the nurse should monitor for respiratory depression and adjust doses only if necessary.

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Correct Answer is B

Explanation

a. A client who has just returned from the PACU:

Vital signs for a client who has just returned from the Post-Anesthesia Care Unit (PACU) are usually obtained by licensed nursing staff due to the potential for complications and the need for close monitoring.

b. A client who has a blood pressure of 110/68 mm Hg:

This client has stable vital signs, and obtaining blood pressure measurements within normal range is a routine task suitable for delegation to assistive personnel.

c. A client who is experiencing chest pain:

Clients experiencing chest pain require immediate assessment by licensed nursing staff or a healthcare provider. This is not a task appropriate for delegation to assistive personnel.

d. A client who has a fasting blood glucose of 104 mg/dL:

Monitoring blood glucose levels is typically within the scope of licensed nursing staff. Delegating tasks related to clients with diabetes or glucose monitoring to assistive personnel may not be appropriate.

A. Review current literature regarding client falls B. Implement a fall prevention plan C. Identify clients who are at risk for falls D. Notify staff of the increased fall rate

Correct Answer is C

Explanation

a. Review current literature regarding client falls:

This option involves conducting a review of existing research and literature on client falls. Reviewing current literature can provide valuable insights into evidence-based practices and interventions for fall prevention. However, conducting a literature review typically follows problem identification and is part of the process of developing an evidence-based approach to addressing the issue.

b. Implement a fall prevention plan:

Implementing a fall prevention plan involves putting in place strategies and interventions aimed at reducing the risk of falls among clients. While implementing a fall prevention plan is an essential step in addressing the issue, it should be based on a thorough assessment of clients at risk for falls (which comes before planning interventions) to ensure that interventions are targeted and effective.

c. Identify clients who are at risk for falls:

This is the most appropriate first step in the quality improvement process. Identifying clients who are at risk for falls allows healthcare providers to focus interventions on those who are most vulnerable. It involves conducting comprehensive assessments, considering factors such as age, mobility, cognitive status, medications, and history of falls, to determine individual risk levels.

d. Notify staff of the increased fall rate:

While communication with staff about the increased fall rate is important for raising awareness and promoting a culture of safety, it should not be the first action taken in the quality improvement process. Before notifying staff, it's essential to identify clients at risk for falls and develop targeted interventions to address the issue effectively.

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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

A nurse is preparing to delegate tasks to an assistive personnel after receiving change-of-shift report. The nurse should assign the AP to obtain vital signs from which of the following clients?

Correct Answer is B

Explanation

A nurse is working on a quality improvement team that is assessing an increase in client falls at the facility. After problem identification, which of the following actions should the nurse plan to take first as part of the quality improvement process?

Correct Answer is C

Explanation

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