Palliative Care (23 Questions)

1. You are visiting Mr. Tremblay, a 78-year-old patient with metastatic prostate cancer, at his home. He is bedbound and has been receiving continuous subcutaneous morphine via a pump for pain control. His wife greets you at the door, visibly distressed. She states, "He has been sleeping almost all the time since yesterday, and his breathing is strange. It stops for a few seconds and then starts again deep and fast. I am afraid to give him the breakthrough dose of medication because he might stop breathing completely." You assess the patient and find he is unarousable, with Cheyne-Stokes respirations and cool, mottled extremities. He does not appear to be in distress.

Question:
What is the most appropriate response to Mrs. Tremblay’s concern regarding the respiratory pattern and the medication? *

"You are right to be concerned; hold all further doses of the medication until his respiratory rate stabilizes above 12."

"This breathing pattern is a normal part of the natural dying process and does not indicate he is suffocating or in pain."

"We should increase his oxygen flow rate to 4 liters to help smooth out his breathing pattern."

"I will call the ambulance immediately to transport him to the hospital for respiratory support."

2. You are caring for Mrs. Cote, a 64-year-old patient with end-stage lung cancer on the palliative care unit. She is conscious but extremely weak. She reports a sensation of "air hunger" and feels like she is suffocating, despite her oxygen saturation being 93% on 2L via nasal cannula. She is anxious and her respiratory rate is 28 breaths/minute. She has already received her scheduled opioid dose.

Question:
In addition to pharmacological interventions (like PRN anxiolytics), what is an effective non-pharmacological nursing intervention to relieve her sensation of dyspnea? *

Place the patient in a supine position with the head of the bed flat to facilitate blood flow to the lungs.

Encourage the patient to take deep, vigorous breaths and hold them for 3 seconds.

Place a portable fan blowing gently directly towards the patient’s face.

Increase the room temperature to prevent shivering and reduce oxygen consumption.

3. Mr. Lavoie, 55, is in the final hours of life due to pancreatic cancer. He is semi-comatose. His family is at the bedside and is very upset because Mr. Lavoie has developed loud, gurgling sounds coming from his throat (death rattle) with every breath. The son asks, "Can't you suction that out? It sounds like he is drowning."

Question:
What is your clinical judgment regarding suctioning in this situation, and what is the appropriate action? *

Perform deep nasotracheal suctioning immediately to clear the airway and reassure the family.

Explain that deep suctioning is often traumatic and causes gagging, and instead administer a prescribed anticholinergic (e.g., Scopolamine or Glycopyrrolate).

Turn the patient onto his back (supine) to allow the secretions to drain down the esophagus.

Increase the IV hydration rate to thin the secretions so they are easier to cough up.

4. You are caring for Mrs. Dubé, an 88-year-old patient with end-stage dementia who is now palliative. She has stopped eating and drinking for the past 3 days. Her daughter is crying and says, "It’s cruel to let her starve and dehydrate to death. Please, can’t you start an IV and give her some fluids?"

Question:
What is the correct physiological explanation to provide to the daughter regarding artificial hydration at the end of life? *

"You are right; we will start IV fluids immediately to extend her life and improve her comfort."

"Starting IV fluids now would likely cause fluid to accumulate in her lungs (congestion) and increase swelling, making her more uncomfortable."

"Dehydration causes severe painful cramps, so we will start a very slow infusion just to keep her mouth moist."

"We cannot give fluids because her veins are too fragile to hold an IV catheter."

5. Mr. Gagnon, 60, has metastatic bone cancer and suffers from severe pain. He is currently receiving Methadone and has a PRN order for Hydromorphone (Dilaudid) for breakthrough pain. You enter the room to assist him with a bed bath and linen change. He tells you that movement causes him excruciating pain (rated 10/10).

Question:
To manage this "incident pain" effectively, what is the best nursing action? *

Proceed with the bath quickly to minimize the duration of the pain.

Administer the PRN Hydromorphone immediately after the bath is completed to help him rest.

Administer the PRN Hydromorphone 20 to 30 minutes before starting the hygiene care.

Apply ice packs to the painful areas while washing him to numb the nerves.

6. You are the nurse for Mrs. Paquette, a patient receiving Palliative Sedation Therapy (PST) for refractory agitated delirium. She is receiving a continuous infusion of Midazolam. Her daughter asks, "Is this the same as Euthanasia or Medical Assistance in Dying (MAID)? Are you killing her?"

Question:
Which statement accurately distinguishes Palliative Sedation from MAID? *

"Yes, it is essentially the same thing, but the medication acts slower."

"Palliative sedation is only used when the patient has requested MAID but is not eligible."

"Palliative sedation stops the heart, whereas MAID stops the breathing."

"No, the goal of palliative sedation is to control unbearable symptoms by lowering consciousness, not to shorten life or cause death."

7. Mr. Roy, 72, is dying of heart failure. He has been restless, moaning, and grimacing for the past hour. The family believes he is in pain, but he is non-verbal. You review his chart and see he has not voided (urinated) in the past 8 hours, despite having an intake of 500 mL.

Question:
Before administering a PRN analgesic or sedative, what is your priority nursing assessment? *

Palpate the suprapubic area to assess for bladder distention.

Check the oxygen saturation to rule out hypoxia.

Assess the pupils for reaction to light.

Call the physician to request an increase in the dosage of Versed (Midazolam).

8. Mrs. Lefebvre is receiving palliative care at home. She has a subcutaneous butterfly catheter installed in her right subclavicular area for medication administration. You arrive to give her a dose of medication and notice the site is red, hard, and the patient winces when you touch the area.

Question:
What is the appropriate action regarding the subcutaneous line? *

Administer the medication slowly and apply a warm compress afterward.

Flush the line with 5 mL of normal saline to check for patency.

Remove the catheter immediately and insert a new one at a different site.

Leave the catheter in place but only use it for hydration, not medication.

9. You are caring for Mr. Caron, who has oral cancer and is near death. He is breathing through his mouth, which is wide open. His lips are dry and cracked, and you note thick white patches on his tongue and inner cheeks (Oral Candidiasis). He appears uncomfortable.

Question:
What is the priority nursing intervention for his oral care? *

Scrub the tongue vigorously with a toothbrush to remove the white patches.

Apply lemon-glycerin swabs to stimulate saliva production.

Provide mouth care every 2 hours using a soft sponge/swab and administer prescribed Nystatin oral suspension.

Syringe 30 mL of water into his mouth every hour to clean it.

11. You are caring for Mr. Giroux, a 58-year-old patient with metastatic colorectal cancer. He has developed a complete bowel obstruction that is inoperable. He is complaining of severe, colicky abdominal cramping and nausea. The physician has ordered medications to manage his symptoms. You see an order for Metoclopramide (Reglan/Maxeran).

Question:
Based on the pathophysiology of a complete bowel obstruction, what is your nursing judgment regarding this prescription? *

Administer the medication immediately to help empty the stomach and relieve nausea.

Hold the medication and contact the physician, as this drug is contraindicated in complete obstruction.

Administer the medication via the rectal route instead of oral to ensure absorption.

Give the medication with a laxative to push the stool through the blockage.

12. Mrs. Boucher, 70, is in the terminal phase of lung cancer. She is currently unconscious. Her daughter and son are at the bedside discussing the funeral arrangements and arguing loudly about the cost of the casket. They believe their mother cannot hear them because she is unarousable.

Question:
Based on your knowledge of the dying process and sensory changes, what is the appropriate nursing intervention? *

Ask the family to step out to the conference room to have this discussion.

Administer a sedative to the patient to ensure she does not become agitated by the noise.

Tell the family that it is fine to stay, but they should whisper.

Ignore the conversation as the patient is in a coma and unaware of her surroundings.

13. Mr. Rioux, 65, has advanced prostate cancer with bone metastases to the spine. He has been mobile and his pain was well-controlled. However, this morning he calls you to report a new, intense band-like pain across his mid-back and states, "My legs feel incredibly heavy and numb when I try to stand up."

Question:
You suspect Spinal Cord Compression, an oncologic emergency. What is your immediate priority action? *

Administer his breakthrough dose of Hydromorphone and reassess in 30 minutes.

Apply a heating pad to the back and help him into a comfortable position in bed.

Instruct the patient to remain on strict bed rest and notify the physician immediately.

Encourage him to walk in the hallway to relieve the stiffness in his legs.

14. Mrs. Landry, 82, died comfortably in her hospital room 20 minutes ago. Her family is present and grieving. You need to prepare the body for transfer to the morgue, but the family is refusing to leave the bedside.

Question:
What is the most appropriate approach to post-mortem care in this situation? *

Inform the family that hospital policy requires the body to be moved within 1 hour.

Gently explain that rigor mortis will set in soon, so you must bathe the body immediately.

Allow the family as much time as they need with the patient, providing privacy and chairs.

Ask the family to wait in the hallway while you quickly remove tubes and wash the body.

15. You are caring for Mr. Tessier, a patient with advanced head and neck cancer. He has a large, fungating tumor on his neck that has eroded into the carotid artery. There is a high risk of a "carotid blowout" (catastrophic terminal hemorrhage). You are preparing the family for this possibility.

Question:
If a massive hemorrhage occurs, what is the priority nursing action to support the patient and family? *

Apply direct pressure, call a Code Blue, and prepare for emergency surgery.

Stay with the patient, use dark-colored towels to absorb the blood, and provide reassurance.

Immediately suction the patient's airway to prevent aspiration of blood.

Leave the room to get the emergency hemorrhage cart and extra gloves.

16. Mrs. Cloutier is taking high-dose oral hydromorphone for cancer pain. She tells you, "I haven't had a bowel movement in 5 days, and my stomach feels hard." You assess her and suspect opioid-induced constipation.

Question:
Which principle regarding opioid use and bowel management is essential for preventing this complication? *

Fiber supplements (like Psyllium/Metamucil) should be started immediately with a large glass of water.

A prophylactic laxative (stimulant and stool softener) should be prescribed and given routinely with opioids.

The opioid dose should be decreased until the bowel movements return to normal.

Encourage the patient to drink prune juice; no medication is needed yet.

17. Mr. Ouellet is in the final stages of COPD and heart failure. He is conscious but suffering from severe, intractable dyspnea (breathlessness) at rest. He is already on maximal oxygen therapy and bronchodilators. The physician suggests starting a low dose of oral Morphine. Mr. Ouellet asks, "Why? I am not in pain."

Question:
How do you explain the therapeutic effect of morphine for dyspnea? *

"It sedates you so you will sleep and not notice the breathing problem."

"It relaxes the muscles in your airways to help them open up."

"It reduces the effort of breathing and the sensation of air hunger, making it easier to breathe."

"It lowers your blood pressure so your heart doesn't have to pump as hard."

18. Mrs. Fortin, 45, has just been transferred to the palliative unit. She is experiencing nausea and vomiting that seems to be related to the chemical effects of her opioids and renal failure (uremia).

Question:
Which antiemetic medication is most effective for nausea caused by chemical triggers (acting on the Chemoreceptor Trigger Zone – CTZ)? *

Dimenhydrinate (Gravol).

Haloperidol (Haldol) or Metoclopramide.

Lorazepam (Ativan).

Scopolamine patch.

19. You are caring for Mr. Leduc, who has esophageal cancer and can no longer swallow his oral medication (dysphagia). He has been taking Hydromorphone 6 mg PO every 4 hours. The physician switches him to a subcutaneous (SC) route.

Question:
When converting an opioid from Oral (PO) to Subcutaneous (SC), what is the general rule regarding the dosage? *

The SC dose should be the same as the PO dose (1:1 ratio).

The SC dose should be double the PO dose because absorption is slower.

The SC dose should be approximately half (50%) of the PO dose because it bypasses the "first-pass" effect.

The medication must be changed to Fentanyl patches as SC hydromorphone is irritating.

20. You are caring for a patient of Indigenous heritage who is in the active phase of dying. The family wishes to perform a "smudging" ceremony (burning sage) in the patient's room to cleanse the spirit. The hospital has a strict "No Open Flame" policy due to oxygen use and fire codes.

Question:
How do you best balance cultural safety with institutional safety regulations? *

Strictly enforce the policy and inform the family they cannot perform the ceremony.

Allow the ceremony to proceed but turn off the room's smoke detector surreptitiously.

Collaborate with the family and the facilities manager to find a safe solution (e.g., turning off O2 temporarily, moving to a designated room, or using a symbolic unlit sage).

Tell the family they can do the ceremony outside in the parking lot.

21. You are the primary nurse caring for Mrs. Gagnon, an 82-year-old patient with end-stage pancreatic cancer and a long history of Type 2 Diabetes. She is currently bedbound, weak, and has a prognosis of days to weeks. Mrs. Gagnon brightens up when she sees you and says, "My daughter is coming to visit me this afternoon, and she promised to bring my favorite chocolate ice cream. I can't wait to share a bowl with her."

Question:
Given her medical history of diabetes and her current palliative status, what is the most appropriate nursing response? *

"That sounds like a lovely idea; enjoying a treat with your daughter is more important right now than worrying about your blood sugar."

"I will check your blood sugar first. If it is below 10 mmol/L, you can have a small amount."

"Unfortunately, because of your diabetes, ice cream is too dangerous. I can ask the kitchen to send up some sugar-free gelatin instead."

"You can have the ice cream, but I will need to administer a sliding-scale dose of insulin immediately afterward."

22. Mr. Tremblay, 75, is in the active phase of dying. He is unconscious, his breathing is shallow, and his extremities are cooling. His wife and two adult sons have been keeping vigil at the bedside for 48 hours. They look exhausted and distressed. The wife comes to the nursing station and says, "We are just sitting there watching him fade away. I feel so useless and helpless. Is there anything we can do for him?"

Question:
To support the family's psychosocial needs and address their feeling of helplessness, what is the best nursing intervention? *

Encourage the family to go home and get some sleep, promising to call them if there is any change.

Suggest that they participate in providing care, such as moistening his lips with a sponge or applying lotion to his hands.

Tell them that their presence in the room is enough and they should not disturb him with physical touch.

Offer to turn on the television in the room to provide a distraction for them while they wait.

23. You are caring for Mr. Lefebvre, a patient with end-stage COPD who is actively dying. He has developed severe respiratory distress: he is gasping for air, using accessory muscles, and appears terrified (air hunger). You prepare to administer the prescribed "Respiratory Distress Protocol" (typically an opioid and an anxiolytic). His daughter, who is at the bedside, grabs your arm and says, "Stop! Don't give him that medication yet. My brother is the legal guardian, and he is driving in from another city. He wants to be here before you sedate Dad. You have to wait."

Question:
The patient is visibly suffering. How do you respond to the daughter to address her concern while upholding your nursing ethical duty? *

"I understand you want your brother here, but my legal obligation is to the patient. I am giving the medication now."

"Okay, we will wait for your brother, but I will increase the oxygen flow to try and help him until then."

"I will call your brother on the phone right now to get his verbal permission to proceed."

"I cannot wait. The purpose of this medication is to relieve this terrifying feeling of suffocation, not to put him in a coma. We need to make him comfortable right now."