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 {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Review with the client and spouse when to notify the physician: Appropriate
Rationale: It is essential to inform the client and their spouse about signs and symptoms that would require notifying the physician, such as increased pain, fever, or unusual symptoms. This helps ensure the client can recognize and report any issues promptly.
Instruct the client to sign their advance directive form: Inappropriate
Rationale: Advance directive forms should be completed well before a surgical procedure and are not typically addressed at the time of discharge following a minor same-day surgery. This is not directly related to the immediate postoperative care and discharge instructions.
Discuss appropriate wound care: Appropriate
Rationale: Providing instructions on how to care for the wound is crucial for preventing infection and promoting proper healing. This information is essential for the client's recovery and should be reviewed before discharge.
Educate on activity limitations: Appropriate
Rationale: Informing the client about activity restrictions helps prevent complications and supports appropriate healing. This education is crucial for ensuring the client follows guidelines that will aid in their recovery.
Provide information about dietary restrictions: Appropriate
Rationale: Depending on the type of surgery and sedation, there may be dietary restrictions or guidelines to follow. Providing this information helps the client manage their diet appropriately after discharge.

A. 0.45% Sodium Chloride B. 10% dextrose in water C. 5% dextrose in water D. 0.9% Sodium Chloride E. Limited ambulation

Correct Answer is ["B"]

Explanation

B. Temperature 38.6°C (101.4°F): An elevated temperature in the postoperative period may indicate an infection, which requires immediate evaluation and management.
A. Heart rate 72 beats/min: This is within the normal range and does not indicate an urgent issue.
C. Surgical dressing dry and intact: This is a positive finding and does not require immediate attention.
D. Pain rating 3 out of 10: This level of pain is manageable and does not indicate a severe issue.
E. Limited ambulation: Limited ambulation is expected post-surgery and does not necessarily indicate an urgent problem.

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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 {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

A client with dry skin and mucous membranes is weak, has orthostatic blood pressure changes, and has decreased urine output. The serum osmolality is 290 mOsm/kg. What IV fluid should the nurse anticipate being prescribed for this client?

Correct Answer is ["B"]

Explanation

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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?