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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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A: 3% Saline
3% Saline is a hypertonic solution, meaning it has a higher concentration of solutes compared to the blood plasma. It is typically used in critical care settings for specific conditions such as severe hyponatremia or cerebral edema. Administering 3% Saline to a patient with a fluid deficit who requires isotonic fluid replacement would not be appropriate because it could lead to cellular dehydration and other complications due to its high osmolarity.
Choice B: Saline 0.45%
Saline 0.45%, also known as half-normal saline, is a hypotonic solution. It has a lower concentration of solutes compared to blood plasma and is used to treat patients with hypernatremia or those who need to be rehydrated without adding too much sodium. However, it is not suitable for isotonic fluid replacement because it can cause cells to swell and potentially burst due to the influx of water into the cells.
Choice C: Saline 0.9%
Saline 0.9%, also known as normal saline, is an isotonic solution. It has the same concentration of solutes as blood plasma, making it ideal for fluid replacement in patients with a fluid deficit. Normal saline is commonly used to expand the extracellular fluid volume without causing significant shifts in fluid between compartments. This makes it the appropriate choice for isotonic fluid replacement.
Choice D: Dextrose 10%
Dextrose 10% is a hypertonic solution used primarily for providing calories in patients who need parenteral nutrition or for treating severe hypoglycemia. It is not suitable for isotonic fluid replacement because its high glucose content can lead to osmotic diuresis and fluid shifts that are not desirable in patients needing isotonic fluids.

A. Properly cleaning all reusable equipment once each day. B. Appropriately using PPE. C. Ensuring all environmental surfaces are properly cleaned, disinfected, and maintained. D. Avoiding all invasive interventions. E. Performing hand washing or using an alcohol-based hand sanitizer before and after patient contact or procedures.

Correct Answer is ["B","C","E"]

Explanation

Choice A: Properly cleaning all reusable equipment once each day

While cleaning reusable equipment is important, it should be done after each use, not just once a day. This ensures that any potential pathogens are removed before the equipment is used on another patient, thereby preventing cross-contamination.

Choice B: Appropriately using PPE

This is a correct answer. Personal Protective Equipment (PPE) such as gloves, masks, gowns, and eye protection are essential in preventing the spread of infection. Proper use of PPE helps protect both healthcare workers and patients from exposure to infectious agents.

Choice C: Ensuring all environmental surfaces are properly cleaned, disinfected, and maintained

This is another correct answer. Regular cleaning and disinfection of environmental surfaces, such as bed rails, doorknobs, and medical equipment, are crucial in preventing the spread of infections. Maintaining a clean environment reduces the risk of healthcare-associated infections.

Choice D: Avoiding all invasive interventions

Avoiding invasive interventions is not a practical or realistic approach to preventing infections. While minimizing unnecessary invasive procedures can reduce infection risk, many invasive interventions are necessary for patient care. Instead, proper aseptic techniques should be used during these procedures to prevent infections.

Choice E: Performing hand washing or using an alcohol-based hand sanitizer before and after patient contact or procedures

This is also a correct answer. Hand hygiene is one of the most effective measures to prevent the spread of infections. Washing hands with soap and water or using an alcohol-based hand sanitizer before and after patient contact or procedures significantly reduces the transmission of pathogens.

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A nurse assesses a postoperative patient 2 days after chest surgery. What four findings indicate that the patient has inadequate pain control?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which IV solution would the nurse anticipate administering to a patient with fluid deficit who requires isotonic fluid replacement?

Correct Answer is C

Explanation

Which three nursing interventions can be used to prevent the spread of infection?

Correct Answer is ["B","C","E"]

Explanation

Neutropenia increases the patient’s risk for life-threatening infection and sepsis.

Instructions: Use this scenario for the next 4 questions. Exhibits Indicate which assessment findings correlate with the nursing problem you identified. (Select all that apply)

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Which term would the nurse use when extracellular fluid and intracellular fluid have the same osmolality?

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Infection prevention strategies include: