In-home hospice care is arranged for a client with stage 4 lung cancer. While the palliative care nurse is arranging for discharge, the client verbalizes concerns about pain. Which action should the nurse implement?

Recommend asking the healthcare professional for a patient-controlled analgesia (PCA) pump.

Explain the respiratory problems that can occur with morphine use.

Teach family how to evaluate the effectiveness of analgesics.

Provide client with a schedule of around-the-clock prescribed analgesic use.

Answer and Explanation

The Correct Answer is D

A. A PCA pump could be considered, but the immediate action should be ensuring the client understands and follows the prescribed pain management regimen.
B. While explaining potential side effects like respiratory depression is important, this action may increase anxiety about pain management rather than address the client's current concern.
C. Teaching the family how to evaluate the effectiveness of analgesics is important but secondary to ensuring the client is consistently receiving pain relief.
D. Providing the client with a schedule of around-the-clock prescribed analgesic use is crucial in managing pain effectively in hospice care. Consistent pain management, rather than waiting for pain to become severe, is a key principle in palliative care to ensure comfort.

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Correct Answer is B

Explanation

A. Leaving the dressing off could increase the risk of infection and delay wound healing. It is important to follow established wound care protocols and consult the healthcare provider if necessary.
B. Applying a hydrocolloidal gel dressing is appropriate for a stage 3 pressure ulcer with significant granulation tissue as it helps maintain a moist wound environment conducive to healing and protects the wound from external contaminants.
C. Replacing gauze with a transparent dressing might not provide adequate moisture control for a granulating wound and could potentially cause damage when removed.
D. Increasing the frequency of dressing changes may not be necessary and could potentially disrupt the healing process. It is important to balance between protecting the wound and allowing it to heal properly.

Correct Answer is []

Explanation

Overflow urinary incontinence: The client's condition, which includes wet clothes and sheets with a small volume of urine voided, suggests overflow urinary incontinence, where the bladder is not completely emptied and leaks small amounts of urine.
Place an incontinence containment product under the client: This action helps manage urinary incontinence by absorbing leaked urine and keeping the client dry, thereby preventing skin breakdown and discomfort.
Provide skin care: Regular skin care is essential to prevent skin irritation, breakdown, and potential infections, especially when the client is incontinent.
Intake and output: Monitoring intake and output is crucial in assessing the client's fluid balance and urinary function, ensuring that the incontinence is managed effectively.
Skin integrity: Monitoring skin integrity is necessary to identify any signs of pressure ulcers or skin breakdown, which can result from prolonged exposure to moisture due to incontinence.

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In-home hospice care is arranged for a client with stage 4 lung cancer. While the palliative care nurse is arranging for discharge, the client verbalizes concerns about pain. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

Correct Answer is B

Explanation

Correct Answer is []

Explanation

The nurse learns that members of the nursing staff are uncomfortable with responding to client family members who are angry. While designing a teaching session to help the staff respond more effectively in these situations, which instructional strategy is best for the nurse to use?

The healthcare provider prescribes cefixime oral suspension 200 mg by mouth twice a day for an older adult who has difficulty swallowing pills. The bottle is labeled, "Cefixime for Oral Suspension, USP 100 mg per 5 mL." How many mL should the nurse administer daily? (Enter numerical value only.)

The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which action is most useful for the nurse to include during the teaching session?

A female client who is receiving hospice care in her home expresses fear that dying will be painful. Which action should the nurse take first?

During the admission assessment to the hospital, a male client reports that he is allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?

While electronically scanning the client's armband at the bedside prior to administering pain medication, the nurse observes the power flickers and the computer screen goes blank. The computer fails to reboot and the screen remains dark. Which action should the nurse do first?

The nurse is caring for a client with obstructive sleep apnea. The nurse should recognize the client is at greater risk for the development of which complication?

A client, who speaks very little English, is being seen in the emergency department following an automobile accident. The client's sibling offers to act as an interpreter and asks about the laboratory results. Which response is best for the nurse to provide?