A nurse assesses a postoperative patient 2 days after chest surgery. What four findings indicate that the patient has inadequate pain control?
Bradypnea
Irritability
Tachycardia
Hypoglycemia
Poor cough effort
Drowsiness
Refusal to participate in physical therapy
Correct Answer : B,C,E,G
Choice A: Bradypnea
Bradypnea, or slow breathing, is not typically associated with inadequate pain control. It is more often related to the effects of certain medications, such as opioids, or underlying respiratory conditions. Inadequate pain control is more likely to cause increased respiratory rate (tachypnea) rather than decreased.
Choice B: Irritability
This is a correct answer. Irritability can be a sign of inadequate pain control. Pain can cause significant discomfort and distress, leading to changes in mood and behavior. Patients who are in pain may become irritable, anxious, or agitated.
Choice C: Tachycardia
This is another correct answer. Tachycardia, or an increased heart rate, can be a physiological response to pain. When a patient is in pain, the body’s stress response is activated, leading to the release of stress hormones like adrenaline, which can increase heart rate.
Choice D: Hypoglycemia
Hypoglycemia, or low blood sugar, is not directly related to pain control. It is more commonly associated with diabetes management, fasting, or certain medications. While it is important to monitor blood sugar levels, hypoglycemia is not a typical indicator of inadequate pain control.
Choice E: Poor cough effort
This is a correct answer. Poor cough effort can indicate inadequate pain control, especially after chest surgery. Pain can make it difficult for patients to take deep breaths or cough effectively, which is essential for preventing respiratory complications such as pneumonia.
Choice F: Drowsiness
Drowsiness is not typically a sign of inadequate pain control. It is more often a side effect of pain medications, particularly opioids. While it is important to monitor for excessive sedation, drowsiness alone does not indicate that pain is not being adequately managed.
Choice G: Refusal to participate in physical therapy
This is the final correct answer. Refusal to participate in physical therapy can be a sign of inadequate pain control. Pain can make movement and physical activity difficult and uncomfortable, leading patients to avoid necessary rehabilitation exercises. Effective pain management is crucial for encouraging participation in physical therapy and promoting recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E","F","G"]
Explanation
Choice A reason:
Potassium (K+) level of 5.6 mEq/L is a critical finding that requires immediate follow-up. Hyperkalemia, defined as a potassium level greater than 5.0 mEq/L, can lead to severe cardiac complications, including arrhythmias and cardiac arrest. The patient’s ECG changes, such as alterations in the T wave and PR interval, indicate that the elevated potassium level is already affecting cardiac function. Immediate intervention is necessary to lower the potassium level and prevent life-threatening complications. Normal potassium levels range from 3.5 to 5.0 mEq/L.
Choice B reason:
BP 109/70 is slightly lower than the normal range but not critically low. While it is important to monitor blood pressure, this finding does not require immediate follow-up compared to the other more critical issues. The patient’s blood pressure should be monitored regularly to ensure it does not drop further, but it is not the most urgent concern at this moment. Normal blood pressure is typically around 120/80 mmHg.
Choice C reason:
No nausea and vomiting is a positive finding indicating that the patient is not losing additional fluids and electrolytes through emesis. While it is important to note, it does not require follow-up as it does not pose an immediate risk to the patient’s health. The absence of nausea and vomiting is beneficial but does not address the primary concerns related to fluid and electrolyte imbalances.
Choice D reason:
Watery diarrhea for 3 days is a significant finding that requires follow-up due to the risk of dehydration and electrolyte imbalances. Diarrhea leads to the loss of fluids and essential electrolytes, which can result in complications such as hypovolemia and electrolyte disturbances. The patient’s ongoing diarrhea needs to be managed to prevent further fluid loss and stabilize their condition. This symptom is directly contributing to the patient’s current state of weakness and electrolyte imbalance.
Choice E reason:
Lightheaded when standing up suggests orthostatic hypotension, which can be a result of dehydration or electrolyte imbalances. This symptom indicates that the patient is experiencing hemodynamic instability, likely due to fluid loss from diarrhea. It is important to address this issue to prevent falls and further complications. Managing the underlying cause, such as rehydration and correcting electrolyte imbalances, will help stabilize the patient’s condition.
Choice F reason:
Blood Urea Nitrogen (BUN) level of 30 mg/dL is elevated, indicating impaired kidney function or dehydration. Normal BUN levels range from 6 to 24 mg/dL. An elevated BUN level suggests that the kidneys are struggling to manage the body’s waste products and fluid balance. This finding is critical for understanding the extent of the patient’s fluid and electrolyte imbalances and guiding appropriate interventions. Addressing the elevated BUN is essential for improving renal function and overall patient health.
Choice G reason:
HR 102 is slightly elevated, indicating tachycardia. Normal heart rate ranges from 60 to 100 beats per minute. Tachycardia can be a sign of dehydration, pain, anxiety, or other underlying conditions. In this case, the elevated heart rate is likely related to the patient’s dehydration and electrolyte imbalances. Monitoring and managing the heart rate is important to ensure the patient’s cardiovascular stability. Interventions to correct fluid and electrolyte imbalances will help normalize the heart rate.
Choice H reason:
Lung sounds are clear is an important assessment finding but does not require follow-up in the context of fluid and electrolyte imbalances. Clear lung sounds indicate that the patient is not experiencing respiratory complications such as pulmonary edema or infection. While this is a positive finding, it does not address the immediate concerns related to the patient’s fluid and electrolyte status.
Correct Answer is A
Explanation
Choice A: True
Neutropenia, characterized by a low count of neutrophils (a type of white blood cell), significantly increases a patient’s risk for life-threatening infections and sepsis. Neutrophils play a crucial role in the immune system by fighting off infections. When their levels are low, the body becomes more susceptible to infections, which can quickly escalate to sepsis if not promptly treated. Neutropenic sepsis is a severe and potentially fatal condition that requires immediate medical intervention. Patients undergoing treatments like chemotherapy are particularly at risk due to their compromised immune systems.
Choice B: False
The statement that neutropenia does not increase the risk for life-threatening infection and sepsis is incorrect. Neutropenia is well-documented as a major risk factor for severe infections and sepsis. Without adequate neutrophils, the body’s ability to combat pathogens is severely impaired, leading to a higher likelihood of infections that can become systemic and life-threatening. Therefore, it is critical to monitor and manage neutropenic patients closely to prevent and treat infections promptly.
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