A nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. The client is reporting pain from muscle spasms. Which of the following actions should the nurse take first?

Obtain a prescription to adjust the weight amount.

Realign the client's position.

Offer a muscle relaxant to the client.

Administer an opioid analgesic.

Answer and Explanation

The Correct Answer is B

B. Muscle spasms can sometimes be triggered or exacerbated by poor positioning or pressure on certain areas of the body. Realigning the client's position will help relieve muscle spasms by reducing pressure or tension on the affected muscles.

A. Adjusting the weight amount in traction may help alleviate pain and muscle spasms by reducing tension on the affected limb. However, realignment should be done first.

C. Muscle relaxants can help alleviate muscle spasms and associated pain by reducing muscle tone and tension. However, realignment should be done first.

D. Opioid analgesics are potent pain relievers that can effectively manage moderate to severe pain, including pain from muscle spasms. However, that should not be the first intervention.

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Correct Answer is D

Explanation

D. Tachypnea is a classic early manifestation of fat embolism syndrome. Fat emboli can travel to the lungs and obstruct blood flow, leading to respiratory distress and hypoxemia. Tachypnea is the body's response to hypoxemia, as it attempts to increase oxygen intake by breathing more rapidly.

A. Swelling of the calf can occur with conditions such as deep vein thrombosis (DVT), but it is not typically an early manifestation of fat embolism syndrome.

B. tachycardia is more commonly seen due to the body's response to decreased oxygen levels and increased demand on the cardiovascular system.

C. Hypertension is not typically associated with fat embolism syndrome. Instead, hypotension can occur due to decreased cardiac output and systemic vasodilation in severe cases of fat embolism syndrome.

A. Emphasize that their spouse may push the pain button when they are uncomfortable B. Provide instructions on decreasing opioid doses by the second postoperative day. C. Teach the patient about how analgesics improve postoperative activity levels. D. Monitor for therapeutic and adverse effects of opioid administration. E. Assess for signs that the patient is becoming addicted to the opioid.

Correct Answer is ["C","D"]

Explanation

C. Education about the benefits of pain management, including how analgesics can improve postoperative activity levels by reducing pain and discomfort, helps to promote the patient's understanding and engagement in their own care.

D. Nurses should closely monitor the patient for both therapeutic effects and adverse effects of opioid administration when using PCA or any other opioid analgesic. Regular assessment allows for prompt identification and management of any complications or side effects.

A. Patient-controlled analgesia (PCA) is designed for the patient to self-administer pain medication according to their own needs and pain levels.

B. Opioid dosing should be individualized based on the patient's pain level and response to the medication. Some patients may require ongoing opioid analgesia for more than two days postoperatively, while others may be able to transition to alternative pain management strategies sooner.

E. Concerns about opioid addiction should not be assumed in all patients, especially those who have never received opioids before. Instead, the focus should be on assessing the patient's pain levels, response to pain medication, and any adverse effects.

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A nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. The client is reporting pain from muscle spasms. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has a pelvic fracture about manifestations of fat embolism syndrome. The nurse should include which of the following findings as an early manifestation?

Correct Answer is D

Explanation

The health care provider orders a patient-controlled analgesia (PCA) machine to provide pain relief for a patient with acute surgical pain who has never received opioids before. Which nursing actions regarding opioid administration are appropriate at this time? (Select all that apply.)

Correct Answer is ["C","D"]

Explanation

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A nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. The client is reporting pain from muscle spasms. Which of the following actions should the nurse take first?

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