A hospice nurse is caring for a client who has 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
The Correct Answer is D
a. Continuing both medications may exacerbate the somnolence and difficulty arousing experienced by the client. It's essential to address the adverse effects promptly.
b. NSAIDs are not typically the first choice for severe pain management in terminal illness, especially when opioids are already prescribed. Moreover, replacing the opioid with an NSAID may not adequately address the pain.
c. Administering the benzodiazepine alongside the opioid may further potentiate the sedative effects and worsen the client's condition.
d. This is the most appropriate action. Withholding the benzodiazepine can help mitigate the sedation while continuing the opioid ensures ongoing pain relief for the client's comfort without introducing additional sedating medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a. While limited social support is important to address for a successful discharge plan, it may not be as urgent as addressing issues directly related to the client's recovery from surgery.
b. Decreased self-esteem is a significant concern but may not directly impact the client's immediate postoperative recovery and discharge plan.
c. Inadequate food supply is important to address for the client's overall well-being but may not be as urgent as addressing issues directly related to the client's recovery from surgery.
d. Low pain tolerance can significantly affect the client's recovery process and may require immediate attention to ensure adequate pain management postoperatively.
Correct Answer is D
Explanation
a. Clients with compromised immunity are often placed in protective environments, but not necessarily in negative air pressure rooms. These rooms are typically reserved for clients on airborne precautions.
b. An N95 respirator is required for airborne precautions, not droplet precautions. A regular surgical mask is sufficient for droplet precautions.
c. Contact precautions primarily focus on preventing the transmission of pathogens through direct or indirect contact. Visitors are usually instructed to wear personal protective equipment (PPE) when entering the room, but the focus is on healthcare workers wearing PPE during patient care.
d. A client on airborne precautions (e.g., for tuberculosis or measles) should wear a mask (preferably an N95 or equivalent) when leaving the room to prevent spreading airborne pathogens
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