A nurse in a long-term care facility is reinforcing teaching about pain control with a client who has terminal cancer. Which of the following information should the nurse include?
Analgesia should be used around the clock to promote pain control.
Pain patches are applied each morning and removed at bedtime.
We will use intramuscular medications to control your pain.
A medication dose must be decreased if you develop tolerance.
The Correct Answer is A
Choice A reason: Using analgesia around the clock is an appropriate action. The nurse should follow the principle of prevention rather than rescue when managing pain for a client who has terminal cancer. The nurse should administer analgesics on a regular schedule to maintain a steady level of pain relief and prevent breakthrough pain.
Choice B reason: Applying pain patches each morning and removing them at bedtime is not an appropriate action. The nurse should follow the manufacturer's instructions for applying and removing pain patches. Some patches are designed to be worn for 24 hours, while others are worn for 72 hours. Removing the patches too soon can cause inadequate pain control and withdrawal symptoms.
Choice C reason: Using intramuscular medications to control pain is not an appropriate action. The nurse should avoid using intramuscular route for administering analgesics to a client who has terminal cancer. Intramuscular injections are painful, unreliable, and increase the risk of infection and bleeding. The nurse should use oral, transdermal, or subcutaneous routes whenever possible.
Choice D reason: Decreasing a medication dose if the client develops tolerance is not an appropriate action. The nurse should understand that tolerance is a normal physiological response to long-term opioid use and does not indicate addiction or abuse. The nurse should adjust the medication dose according to the client's level of pain and response to treatment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Wiping the top of the feeding container with alcohol is not a priority action, as it is not essential for infection control or safety. The nurse should use a sterile technique when opening and handling the feeding container.
Choice B reason: Placing the head of the client's bed at a 30° angle or higher is a priority action, as it can prevent aspiration or regurgitation of the feeding solution into the lungs, which can cause pneumonia or respiratory distress.
Choice C reason: Rinsing the feeding bag with water once the feeding is complete is not a priority action, as it can be done after ensuring that the client has tolerated the feeding well and has no signs of complications.
Choice D reason: Documenting the client's response to the feeding is not a priority action, as it can be done after performing other interventions and assessments that are more urgent and important for the client's well-being.
Correct Answer is A
Explanation
Choice A reason: Changed mental status, such as confusion, agitation, or delirium, can be a sign of a bladder infection in older adults, as they may not have the typical symptoms of dysuria, frequency, or urgency.
Choice B reason: WBC count 9,000/mm³ is within the normal range of 4,500 to 11,000/mm³ and does not indicate an infection.
Choice C reason: Diminished reflexes are not related to a bladder infection and may be due to aging, neurological disorders, or medication side effects.
Choice D reason: Temperature 37.3°C (99.1°F) is slightly elevated but not indicative of a bladder infection. Older adults may have lower baseline temperatures and may not develop fever in response to an infection.
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