# A hospice nurse is planning pain management for a client with metastatic cancer who can take oral medications and reports moderate-to-severe pain rated 7/10 most of the day. Which interventions belong in an evidence-based end-of-life pain-management plan? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=363998&lang=en  
> language: en  
> subject: Personal Hygiene  
> category: BCC

## Question

A hospice nurse is planning pain management for a client with metastatic cancer who can take oral medications and reports moderate-to-severe pain rated 7/10 most of the day. Which interventions belong in an evidence-based end-of-life pain-management plan? Select all that apply.

1

Administer scheduled around-the-clock long-acting opioid (e.g., extended-release morphine) with as-needed immediate-release opioid for breakthrough pain

2

Hold all opioids whenever the respiratory rate is below 12/min despite severe pain, without assessing sedation, ventilation, goals of care, or the prescribed plan

3

Add an adjuvant analgesic such as a corticosteroid for bone pain or gabapentin for neuropathic pain when opioids alone are insufficient

4

Use a validated pain assessment tool appropriate to the client's cognitive level, such as numeric rating, FLACC for non-verbal clients, or PAINAD for advanced dementia

5

Implement non-pharmacologic comfort measures including therapeutic positioning, mouth care, music, and presence of family at the bedside

6

Initiate a bowel regimen at the start of opioid therapy and treat opioid-related nausea proactively to keep the client comfortable

## Explanation

Evidence-based end-of-life cancer pain management uses scheduled long-acting opioids with immediate-release rescue doses for breakthrough pain (Choice 1), adjuvants for specific pain types (Choice 3), validated pain tools matched to cognitive and communication ability (Choice 4), nonpharmacologic comfort measures (Choice 5), and proactive management of common opioid adverse effects when consistent with the client's condition and goals (Choice 6). Opioids should be titrated to relieve suffering while sedation and ventilation are assessed; an arbitrary respiratory-rate cutoff alone does not justify withholding all analgesia without considering the full clinical picture and prescribed plan (Choice 2). The route and bowel regimen should be individualized if swallowing or intake declines as death becomes imminent.

## In-depth explanation

Hospice Pain Management Pillars
1. Scheduled long-acting + PRN breakthrough opioid
2. Adjuvants targeted to pain type (steroids for bone, gabapentin for neuropathic, antispasmodics)
3. Non-pharm comfort (position, oral care, music, presence)
4. Validated assessment matched to cognition
5. Proactive side-effect management — bowel regimen from day 1 of opioid

Principle of Double Effect
Giving opioids to relieve suffering at end of life is ethically and legally appropriate even if a foreseen but unintended secondary effect is hastened death. The intent is comfort.

Memory Tip
"SAVED": Scheduled opioid, Adjuvants, Validated tools, Environment (non-pharm), Difficult side-effects anticipated.

Caution
Withholding opioids based on respiratory rate alone in hospice is not appropriate. Use clinical judgment, family wishes, and goals of care.

## Clinical scenario

Scenario
Metastatic cancer, actively dying phase. Pain 7/10 most of day. Family at bedside. POLST documents comfort-focused care, no transfer to hospital. Goals = comfort and dignity.

Multimodal Pain Plan
- Around-the-clock: ER morphine (or methadone, fentanyl patch)
- Breakthrough: IR morphine 10-15% of 24-hr dose, q1h PRN
- Adjuvants: dexamethasone for bone pain; gabapentin/pregabalin for neuropathic
- Non-pharm: position changes, mouth care q2h, music, presence
- Side effects: senna + docusate at start, ondansetron PRN

Family Education
Reassure that opioid use at end of life does not "hasten death" when titrated for symptom control. Address fear of addiction (irrelevant in hospice).

## Key concepts

- **Principle of double effect** — Ethical and legal principle: an action that has a good primary effect (relief of suffering) and a foreseen but unintended secondary effect (possibly shortening life) is ethically permissible if the intent was the good effect and the means were proportionate. Foundational for hospice/palliative analgesia.
- **Adjuvant analgesics** — Drugs whose primary indication is not pain but that potentiate analgesia or treat specific pain types: corticosteroids (bone pain, nerve compression), gabapentinoids (neuropathic), TCAs/SNRIs (neuropathic), bisphosphonates (bone metastases), antispasmodics (visceral pain).
- **Pain assessment tools by cognition** — Numeric rating scale (NRS, 0-10) for verbal cognitively intact clients; Wong-Baker FACES for children/literacy issues; FLACC for non-verbal infants/adults; PAINAD (Pain Assessment in Advanced Dementia) for clients with advanced dementia. Match the tool to the client.

## Related questions

- [A nurse is creating a pressure injury prevention plan for an immobile older adult admitted…](https://mymerci.kr/pages/nclex_q.php?qn_id=366392&lang=en)
- [A dying client's family asks to perform meaningful spiritual and cultural rituals at the b…](https://mymerci.kr/pages/nclex_q.php?qn_id=368302&lang=en)
- [A nurse cares for family members after a loved one is told that an illness is terminal. Wh…](https://mymerci.kr/pages/nclex_q.php?qn_id=368324&lang=en)
- [A 62-year-old client with chronic low-back pain has taken sustained-release morphine 30 mg…](https://mymerci.kr/pages/nclex_q.php?qn_id=369152&lang=en)
- [A community health nurse is leading an advance care planning education session at a senior…](https://mymerci.kr/pages/nclex_q.php?qn_id=372705&lang=en)
- [Stage 4 — Generate solutions. Select all nursing actions that belong in Mr. K's individual…](https://mymerci.kr/pages/nclex_q.php?qn_id=372807&lang=en)
- [Stage 5 — Take action. Place the five nursing actions in the safest sequence for the initi…](https://mymerci.kr/pages/nclex_q.php?qn_id=372808&lang=en)
- [Stage 6 — Evaluate outcomes. Review the day-shift trajectory and answer the three question…](https://mymerci.kr/pages/nclex_q.php?qn_id=372809&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=363998&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=363998&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=363998&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=363998&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=363998&lang=vi)

---

More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en)

_For study reference only. Always follow current clinical guidelines and your institution’s protocols._