A client with acute pain is prescribed a sustained-release opioid that is administered every 12 hours. After 6 hours, the client complains of increasing pain that is rated as 9/10. Which intervention by the nurse is most appropriate to address the client's pain?

Teach the client a relaxation technique to use until the next dose is due.

Obtain an order for an immediate-release opioid for breakthrough pain.

Explain to the client that the medication being administered lasts for 12 hours.

Assess the client's vital signs and administer the next dose of opioids early.

Answer and Explanation

The Correct Answer is B

A. Teach the client a relaxation technique to use until the next dose is due: While relaxation techniques can be helpful in managing pain, they are not sufficient for severe pain rated 9/10. The client requires more immediate pharmacological intervention.
B. Obtain an order for an immediate-release opioid for breakthrough pain: This is the most appropriate action. Immediate-release opioids are specifically used to manage breakthrough pain in clients on sustained-release opioid therapy. It addresses the client's severe pain effectively and promptly.
C. Explain to the client that the medication being administered lasts for 12 hours: Simply explaining the duration of the medication does not address the client's current severe pain. Effective pain management requires action, not just education.
D. Assess the client's vital signs and administer the next dose of opioids early: Administering the next dose early can lead to inappropriate dosing schedules and potential overdose. It is important to follow the prescribed dosing regimen and manage breakthrough pain appropriately.

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Correct Answer is C

Explanation

A. Capillary refill and depth of peripheral edema: While these assessments are important for evaluating peripheral circulation and fluid status, they are not as immediately critical given the client's new onset of confusion and respiratory symptoms.
B. Abdominal sounds and obtain a BNP level: Assessing abdominal sounds and BNP (B-type natriuretic peptide) levels is useful for diagnosing heart failure exacerbations but is secondary to addressing the client's acute confusion and potential electrolyte imbalances.
C. Neurological status and obtain electrolyte levels: This is the correct choice. New onset confusion can be indicative of electrolyte imbalances or acute exacerbations related to heart failure. Monitoring neurological status and electrolyte levels is crucial to address potential causes of confusion and ensure proper treatment.
D. Skin turgor and measure intake & output (I&O): While skin turgor and I&O are relevant for assessing fluid status, the priority should be addressing the acute change in mental status and potential underlying causes such as electrolyte imbalances.

A. Discontinue use of supplemental oxygen B. Encouraging use of incentive spirometer C. Implement fluid restrictions D. Administering an antitussive agent

Correct Answer is B

Explanation

A. Discontinue use of supplemental oxygen: This option is incorrect because supplemental oxygen is used to increase the oxygen levels in the blood, which is not directly related to addressing respiratory acidosis. In respiratory acidosis, the problem is primarily with the elimination of CO2 rather than oxygenation.
B. Encouraging use of incentive spirometer: This is the correct choice as using an incentive spirometer helps improve lung expansion and promotes alveolar ventilation, which aids in reducing CO2 levels in the blood, thereby addressing respiratory acidosis.
C. Implement fluid restrictions: This option is not suitable because fluid restrictions do not directly address the underlying issue of respiratory acidosis. Fluid restrictions might be necessary for other conditions, but they are not effective in correcting respiratory acid-base imbalances.
D. Administering an antitussive agent: This is incorrect because antitussive agents suppress cough reflexes, which can be counterproductive. In respiratory acidosis, coughing is often a protective mechanism to help clear secretions, so suppressing it may worsen the acid-base imbalance.

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A client with acute pain is prescribed a sustained-release opioid that is administered every 12 hours. After 6 hours, the client complains of increasing pain that is rated as 9/10. Which intervention by the nurse is most appropriate to address the client's pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Arterial blood gases on a postoperative client with pneumonia indicate the client is in respiratory acidosis. To best improve this acid-base imbalance, which intervention should the nurse implement?

Correct Answer is B

Explanation

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