A client with metastatic cancer reports a pain level of 10 on a scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which intervention is most important for the nurse to include in this client's plan of care?

Replace transdermal analgesic patches every 72 hours.

Administer analgesics on a fixed and continuous schedule.

Monitor client for break through pain.

Frequently evaluate the client's pain.

Answer and Explanation

The Correct Answer is C

C. Breakthrough pain is a transient exacerbation of pain that occurs despite the use of around- the-clock analgesics for persistent pain. Breakthrough pain episodes require rapid intervention with additional analgesics or adjustments to the current pain management regimen to provide adequate pain relief and improve the client's quality of life.
A. Replacing transdermal analgesic patches every 72 hours is important for ensuring consistent delivery of medication, but it is not directly related to addressing breakthrough pain.
B. Administering analgesics on a fixed and continuous schedule is important for maintaining baseline pain control, but it may not address breakthrough pain adequately.
D. Frequently evaluating the client's pain is essential, but monitoring specifically for breakthrough pain ensures timely intervention when pain exacerbations occur.

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Correct Answer is B

Explanation

B. An increase in pain after cast placement could indicate complications such as compartment syndrome, which is a serious condition that occurs when increased pressure within a confined space (such as the area within the cast) compromises circulation and tissue perfusion. Assessing the radial pulse volume on the affected arm is crucial to evaluate perfusion distal to the fracture site.
A. Distraction technique may help manage the client's pain but does not address the underlying cause of the pain increase, which could be related to compromised circulation.
C. Analgesics relieve pain but do not address the immediate limb threatening issue at hand.
D. Measuring blood pressure is not directly related to assessing circulation distal to the fracture site.

A. Sitting upright B. Tightness in the chest C. Medication compliance D. Respirations of 28 breaths/minute E. Restlessness F. Dyspnea G. Pulse oxygenation of 85%

Correct Answer is ["A","B","D","E","F","G"]

Explanation

A. Patients with respiratory distress often prefer to sit upright or in a tripod position to ease breathing by allowing maximal lung expansion. Sitting upright helps relieve pressure on the diaphragm and allows better air exchange in the lungs.
B. Chest tightness is a common symptom of various respiratory conditions, such as asthma, chronic obstructive pulmonary disease (COPD), or pneumonia. It can result from bronchoconstriction, inflammation, or accumulation of mucus in the airways, leading to difficulty breathing.
D. An increased respiratory rate (tachypnea) may indicate respiratory distress or difficulty breathing. Tachypnea is a compensatory mechanism to increase oxygen intake or remove carbon dioxide from the body when lung function is compromised.
E. Restlessness can be a cue for a respiratory problem. Patients experiencing respiratory distress may exhibit restlessness due to hypoxia (low oxygen levels), discomfort, or anxiety related to difficulty breathing.
F. Dyspnea, or shortness of breath, is a significant cue for a respiratory problem. It is a common symptom of various respiratory conditions, including asthma, COPD, pneumonia, and pulmonary embolism. Dyspnea may range from mild to severe and can significantly impact the patient's quality of life and functional status.
G. A pulse oxygenation level of 85% indicates hypoxemia (low blood oxygen levels) and is a significant cue for a respiratory problem. Hypoxemia can result from various respiratory conditions or inadequate ventilation and may lead to tissue hypoxia and organ dysfunction if left untreated.
C. Medication compliance is not directly indicative of a respiratory problem. However, it may be relevant to managing respiratory conditions if the patient requires medications such as bronchodilators or corticosteroids to control symptoms or prevent exacerbations.
H. While an elevated heart rate (tachycardia) can be associated with respiratory distress, it is not specific to respiratory problems and may occur in response to other stressors or medical conditions.
I. Body mass index (BMI) is a measure of body fat based on height and weight and is not directly indicative of a respiratory problem. However, obesity is a risk factor for respiratory conditions such as obstructive sleep apnea and obesity hypoventilation syndrome.

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A client with metastatic cancer reports a pain level of 10 on a scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which intervention is most important for the nurse to include in this client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a right ulnar fracture and cast placement reports an increase in arm pain. Which action should the nurse take next?

Correct Answer is B

Explanation

Patient Data Exhibits What finding(s) are cues for a respiratory problem? Select all that apply.

Correct Answer is ["A","B","D","E","F","G"]

Explanation

A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding is most important for the nurse to monitor?

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A client who fractured the right femur from a fall at home is placed in traction while awaiting surgery. When the client informs the nurse of the need to urinate, which intervention should the nurse implement?

A client with metastatic cancer reports a pain level of 10 on a scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which intervention is most important for the nurse to include in this client's plan of care?

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