# A 78-year-old with end-stage pancreatic cancer is admitted to the medical ward. After reviewing the EHR tabs (History, Vitals, Labs, Notes, Orders), which intervention should the nurse prioritize first? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=372916&lang=en > language: en > subject: Basic Care and Comfort > category: BCC ## Question A 78-year-old with end-stage pancreatic cancer is admitted to the medical ward. After reviewing the EHR tabs (History, Vitals, Labs, Notes, Orders), which intervention should the nurse prioritize first? History Vitals Labs Orders Notes 78-year-old female. Stage IV pancreatic adenocarcinoma diagnosed 9 months ago, declining further chemotherapy. Lives with spouse; daughter is healthcare proxy. Five Wishes / advance directive on file: comfort measures, DNR/DNI, no artificial nutrition or hydration. BP 102/64, HR 96, RR 22, SpO2 91% on 2 L NC, T 37.1 C, Pain 6/10 in epigastrium, dyspnea at rest. Hgb 8.6 g/dL, albumin 2.4 g/dL, total bilirubin 4.8 mg/dL, BUN 38 mg/dL — labs consistent with disease trajectory; team has agreed not to retrend. Morphine 2-4 mg SC q2h PRN pain or dyspnea. Senna 2 tabs PO BID. Polyethylene glycol 17 g PO daily PRN. Reposition q2h for comfort. Mouth care q2h. Family permitted at bedside. Hospice consult completed; family meeting documented. Goal-of-care: comfort. Patient verbalizes pain control and feeling less short of breath as primary goals. No further imaging or aggressive workup planned per family meeting note. 1 Encourage oral intake of high-calorie nutritional supplements every 2 hours to address weight loss. ✕ 2 Initiate scheduled morphine and a bowel regimen for pain and dyspnea, and reposition every 2 hours for skin and comfort. ✕ 3 Place a nasogastric tube for tube feeding to prevent further nutritional decline. ✕ 4 Schedule a chest x-ray and comprehensive metabolic panel to evaluate worsening dyspnea. ✕ ## Explanation The patient has a documented comfort-focused goal of care, DNR/DNI, and is on hospice consult. The priority is symptom management — scheduled opioid for pain and dyspnea (morphine is first-line for both), bowel regimen to prevent opioid constipation, and gentle repositioning for skin integrity and comfort. Aggressive nutritional support (1, 3) and diagnostic workup (4) contradict the documented comfort plan. ## In-depth explanation In palliative care, the rule is "treat symptoms, not numbers." Morphine relieves dyspnea by reducing respiratory drive sensitivity to CO2 — not by sedation. NG feeding and aggressive workup at end of life can prolong suffering without prolonging life and conflict with comfort-focused goals. ## Clinical scenario **78-year-old with end-stage pancreatic cancer** on the medical ward. Goals-of-care discussion documented. The nurse reviews the chart and plans the shift. ## Key concepts - **Comfort-focused goals of care** — Goals shift from cure/life-prolongation to symptom relief and quality of life as documented in advance directives or family meetings. - **Morphine for dyspnea** — Low-dose opioid (e.g., 2-4 mg PO/SC) is first-line palliative therapy for refractory dyspnea — reduces air hunger. - **Opioid bowel regimen** — Stimulant laxative (senna) +/- osmotic (PEG); prescribed prophylactically when scheduled opioids start. ## Related questions - [A patient with cirrhosis and grade 2 hepatic encephalopathy has been started on lactulose.…](https://mymerci.kr/pages/nclex_q.php?qn_id=372852&lang=en) - [A patient is in the active dying phase from end-stage heart failure. 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