A client with cancer stage T4, N3, M1 is ordered morphine sulfate 4 mg, subcutaneous every 3 to 4 hours. Two hours after the last injection, the client rings the call bell to report a pain scale of 9 . Which is the appropriate action by the nurse?

Question

A) Explain to the client that the medication can only be given every 3 to 4 hours.
B) Ignore the call bell and stall until it is time to administer the next dose.
C) Notify the physician of the breakthrough pain in an attempt to obtain additional orders.
D) Ask the family to attempt diversion activities until the next dose can be given.

Answer 1

C
Feedback:
Pain is a major problem for clients with metastatic cancer, and control of the pain is a priority. Explaining to the client is not appropriate and will not correct the issue of pain. Ignoring the client is a form of neglect and violates the rights of the client to receive prompt care. Although diversion techniques (meditation, prayer, yoga, music therapy, etc.) can be used to lessen pain, the family should not be asked to complete nursing care.