Nokea
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?
- A. Withhold the benzodiazepine but continue the opioid.
- B. Administer the benzodiazepine but withhold the opioid.
- C. Continue the medication dosages that relieve the client's pain.
- D. Contact the provider about replacing the opioid with an NSAID.
Correct Answer: A
Rationale: The correct answer is A: Withhold the benzodiazepine but continue the opioid. Benzodiazepines can potentiate the sedative effects of opioids, leading to increased somnolence and difficulty arousing the client. By withholding the benzodiazepine, the nurse can help decrease the sedative effects, allowing the client to become more responsive while still receiving pain relief from the opioid. Continuing the opioid ensures that the client's pain is adequately managed. Administering the benzodiazepine alone (choice B) may exacerbate the sedative effects. Continuing the medication dosages (choice C) without adjusting the benzodiazepine dose may not address the sedation issue. Contacting the provider about replacing the opioid with an NSAID (choice D) is not indicated as opioids are typically the mainstay for managing severe pain in terminal illness.
You may also like to solve these questions
A nurse overhears two assistive personnel (AP) discussing a client's care in the cafeteria. Which of the following actions should the nurse take?
- A. Notify the client's provider about the incident.
- B. Instruct the AP to discontinue the conversation.
- C. Complete an incident report about the breach of client confidentiality.
- D. Reassign the AP to other clients on the unit.
Correct Answer: B
Rationale: The correct answer is B: Instruct the AP to discontinue the conversation. The nurse should address the situation immediately by instructing the AP to stop discussing the client's care in a public setting like the cafeteria to maintain client confidentiality. This action prevents further breach of confidentiality and reinforces the importance of respecting privacy. Notifying the provider (A) may be necessary later, but the immediate action should be to stop the conversation. Completing an incident report (C) is important for documentation but is not the first step. Reassigning the AP (D) may not address the root issue of confidentiality breach.
A nurse is preparing a client for surgery. The client expresses concern that someone might steal her purse during the procedure. Which of the following actions should the nurse take?
- A. Offer to store the purse at the nurses' station.
- B. Tell the client to leave her purse in a drawer of the bedside table.
- C. Place the purse in the clothing bag with the client's other belongings.
- D. Offer to place the purse in the facility safe.
Correct Answer: D
Rationale: The correct answer is D: Offer to place the purse in the facility safe. This is the best option as it ensures the client's belongings are kept secure during the surgery. Storing the purse at the nurses' station (A) may not guarantee its safety. Leaving the purse in a drawer (B) or clothing bag (C) can also pose a risk of theft. Placing it in the facility safe (D) is the most secure and professional solution to address the client's concern.
A client scheduled for a tubal ligation procedure starts to cry as she is wheeled into the surgical suite. Which of the following nursing statements is an appropriate nursing response?
- A. It's not too late to cancel the surgery if you want to.
- B. This won't take long and it will be over before you know it.
- C. Why did you make the decision to have this procedure?
- D. You shouldn't be worried because the procedure is very safe.
Correct Answer: A
Rationale: Correct Answer: A. "It's not too late to cancel the surgery if you want to."
Rationale: This response acknowledges the client's emotions and empowers her to make a decision based on her feelings. It shows empathy and respect for her autonomy in making choices about her own body.
Summary of Other Choices:
B: This response dismisses the client's emotions and may come off as insensitive.
C: Asking why the client made the decision can be perceived as judgmental and may increase anxiety.
D: This response invalidates the client's feelings and may not provide reassurance effectively.
A nurse is serving on a committee whose task is to plan cost-effective care at the facility. Which of the following client care tasks should the nurse recommend?
- A. Change total parenteral nutrition IV tubing every 48 hr.
- B. Replace total parenteral nutrition solution bags every 48 hr.
- C. Replace peripheral IV solution bags every 96 hr.
- D. Change peripheral IV primary tubing every 96 hr.
Correct Answer: D
Rationale: The correct answer is D: Change peripheral IV primary tubing every 96 hr. This recommendation aligns with evidence-based practice guidelines for preventing infection risk associated with IV therapy. Changing the peripheral IV tubing every 96 hours helps reduce the risk of contamination and infection. Choice A is incorrect because changing total parenteral nutrition IV tubing every 48 hours is not necessary unless there is a specific indication. Choice B is incorrect as replacing total parenteral nutrition solution bags every 48 hours is not a standard practice and can lead to wastage. Choice C is incorrect because changing peripheral IV solution bags every 96 hours is less critical than changing the primary tubing.
A nurse on a medical surgical unit is caring for a group of clients with the assistance of a licensed practical nurse (LPN) and assistive personnel. Which of the following tasks should the nurse assign to the LPN?
- A. Providing postmortem care for a client who has just died
- B. Reinforcing dietary teaching with a client who has heart disease
- C. Accompanying a client who just had a wound debridement to physical therapy
- D. Obtaining a urine specimen from an older adult client
Correct Answer: D
Rationale: The correct answer is D, assigning the task of obtaining a urine specimen from an older adult client to the LPN. This task falls within the scope of practice for an LPN as it involves basic nursing skills and does not require critical thinking or assessment. LPNs are trained to perform routine procedures such as specimen collection under the supervision of a registered nurse. Providing postmortem care (A) requires emotional support and specialized knowledge beyond the LPN's scope. Reinforcing dietary teaching (B) and accompanying a client to physical therapy (C) involve critical thinking and assessment skills that are typically within the RN's scope. Therefore, D is the correct choice.