Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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. Administer the benzodiazepine but withhold the opioid.
Withholding the opioid may lead to inadequate pain relief, which isn't the best approach, especially in a terminally ill patient experiencing severe pain.
B. Continue the medication dosages that relieve the client's pain.
Continuing the medication dosages that relieve pain is important for the client's comfort, even if it causes somnolence.
C. Contact the provider about replacing the opioid with an NSAID.
Contacting the provider to consider an NSAID might be an option, but immediate relief should not be compromised while awaiting a change in medication.
D. Withhold the benzodiazepine but continue the opioid.
Withholding the benzodiazepine might be considered if the sedation is excessive, but prioritizing pain relief is crucial in end-of-life care unless there are severe adverse effects.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Leadership 2019 Proctored Exam. Take the full exam now
Full Explanation
A. Withholding the opioid may lead to inadequate pain relief, which isn't the best approach, especially in a terminally ill patient experiencing severe pain.
B. Continuing the medication dosages that relieve pain is important for the client's comfort, even if it causes somnolence.
C. Contacting the provider to consider an NSAID might be an option, but immediate relief should not be compromised while awaiting a change in medication.
D. Withholding the benzodiazepine might be considered if the sedation is excessive, but prioritizing pain relief is crucial in end-of-life care unless there are severe adverse effects.
Similar Questions
A nurse in an ambulatory care setting is orienting a newly licensed nurse who is preparing to return a call to a client. The nurse should explain that which of the following is an objective of telehealth?
A. Establishing communication between providers
Telehealth often facilitates communication between healthcare providers, enabling consultations, collaboration, and information exchange regardless of physical location.
B. Assessing client needs
While telehealth can involve assessment components, its primary objective isn't specifically focused on assessing client needs.
C. Providing medication reconciliation
Medication reconciliation is an important aspect of healthcare but might not be the primary objective of telehealth.
D. Developing client treatment protocols
Developing client treatment protocols is more related to clinical decision-making and might not be the primary objective of telehealth, which often centers around communication andremote care delivery.
Full Explanation
A. Telehealth often facilitates communication between healthcare providers, enabling consultations, collaboration, and information exchange regardless of physical location.
B. While telehealth can involve assessment components, its primary objective isn't specifically focused on assessing client needs.
C. Medication reconciliation is an important aspect of healthcare but might not be the primary objective of telehealth.
D. Developing client treatment protocols is more related to clinical decision-making and might not be the primary objective of telehealth, which often centers around communication and
remote care delivery.
A nurse on a medical-surgical unit is caring for a group of clients with the assistance of a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN?
A. Accompanying a client who just had a wound debridement to physical therapy
Accompanying a client to physical therapy is a task that can be appropriately delegated to an AP, as it does not require clinical judgment or advanced nursing knowledge. This task does not require the skills of an LPN.
B. Reinforcing dietary teaching with a client who has heart disease
Reinforcing dietary teaching with a client who has heart disease is within the scope of practice for an LPN. LPNs can reinforce teaching that has already been initiated by the registered nurse (RN). This task involves some level of knowledge and skill but does not require independent clinical judgment, making it suitable for the LPN.
C. Obtaining a urine specimen from an older adult client
Obtaining a urine specimen from an older adult client is a task that can be delegated to an AP, as it is a routine procedure that does not require nursing assessment or decision-making. This task does not require the skills of an LPN.
D. Providing postmortem care for a client who has just died
Providing postmortem care for a client who has just died is a task that can be appropriately delegated to an AP. This task involves following established protocols and does not require clinical judgment or advanced nursing skills. It is not necessary to assign this task to an LPN.
None
Full Explanation
A. Accompanying a client to physical therapy is a task that can be appropriately delegated to an AP, as it does not require clinical judgment or advanced nursing knowledge. This task does not require the skills of an LPN.
B. Reinforcing dietary teaching with a client who has heart disease is within the scope of practice for an LPN. LPNs can reinforce teaching that has already been initiated by the registered nurse (RN). This task involves some level of knowledge and skill but does not require independent clinical judgment, making it suitable for the LPN.
C. Obtaining a urine specimen from an older adult client is a task that can be delegated to an AP, as it is a routine procedure that does not require nursing assessment or decision-making. This task does not require the skills of an LPN.
D. Providing postmortem care for a client who has just died is a task that can be appropriately delegated to an AP. This task involves following established protocols and does not require clinical judgment or advanced nursing skills. It is not necessary to assign this task to an LPN.
A nurse is teaching newly licensed nurses about client confidentiality. The nurse should include that which of the following examples represents a violation of client confidentiality?
A. Calling the pharmacy with a prescription for the client's partner to pick up
Calling the pharmacy for a prescription for the client's partner doesn't necessarily violate client confidentiality as it pertains to the partner's care.
B. Providing a copy of the client's medical record to the transporting paramedic
Providing a copy of the client's medical record to a third party, the transporting paramedic, breaches confidentiality as it exposes the client's private health information to someone notinvolved in direct care.
C. Reporting a client's disposition to the referring provider
Reporting a client's disposition to the referring provider is part of normal care coordination and doesn't typically violate confidentiality.
D. Informing housekeeping staff that the client is in the dialysis unit
Informing housekeeping staff about a client's location in a specific unit doesn't divulge confidential health information.
Full Explanation
A. Calling the pharmacy for a prescription for the client's partner doesn't necessarily violate client confidentiality as it pertains to the partner's care.
B. Providing a copy of the client's medical record to a third party, the transporting paramedic, breaches confidentiality as it exposes the client's private health information to someone not
involved in direct care.
C. Reporting a client's disposition to the referring provider is part of normal care coordination and doesn't typically violate confidentiality.
D. Informing housekeeping staff about a client's location in a specific unit doesn't divulge confidential health information.