A patient who is receiving sustained-release morphine sulfate (MS Contin) every 12 hours for chronic pain experiences level 9 (0 to 10 scale) breakthrough pain and anxiety. Which action by the nurse is appropriate for treating this change in assessment?

Administer lorazepam (Ativan) 1 mg orally.

Offer immediate-release morphine 30 mg orally.

Suggest the patient take amitriptyline 10 mg orally.

Give Ibuprofen 400 to 800 mg orally.

Answer and Explanation

The Correct Answer is B

B. Immediate-release morphine provides rapid pain relief and can effectively address breakthrough pain. The dose of 30 mg is reasonable given the severity of the pain.

A. Lorazepam is a benzodiazepine used to treat anxiety. While it may help with anxiety, it does not directly address the severe breakthrough pain experienced by the patient.

C. Amitriptyline is a tricyclic antidepressant used to treat neuropathic pain and depression. While it may help with chronic pain management, it is not appropriate for providing rapid relief for breakthrough pain or acute anxiety.

D. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) commonly used for mild to moderate pain relief and inflammation. However, it is not typically used for severe breakthrough pain, especially in a patient already receiving opioid therapy.

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Correct Answer is C

Explanation

C. Maintaining immobilization and alignment of the fractured bone is essential for allowing the bone to heal properly. Immobilization prevents further injury and displacement of the fracture fragments, while proper alignment ensures optimal bone healing and functional outcomes.

A. Optimal nutrition and hydration may not be the highest priority compared to other interventions that directly address the fracture management and functional healing.

B. Providing relief from pain and discomfort is crucial for the client's comfort and well-being, but it may not be the highest priority in achieving functional healing.

D. Promoting independence in activities of daily living is important for the client's overall well-being and quality of life, but it may not be the highest priority immediately after a fracture.

A. Elastic bandages secure around the traction ropes B. Minimal edema around the pin C. Slight pain at the insertion site D. Serous drainage on the dressing E. Movement of the pin at the insertion site

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

Explanation

B. Minimal edema (swelling) around the pin insertion site is an expected finding in clients with skeletal traction. Some degree of swelling may occur due to tissue trauma and the presence of foreign objects (such as the traction pins) within the soft tissues.

C. Slight pain or discomfort at the pin insertion site is common in clients with skeletal traction. The presence of traction pins can cause irritation or discomfort, especially during movement or weight- bearing activities.

A. Elastic bandages are not typically used to secure traction ropes in skeletal traction. Traction is usually maintained using specialized devices or weights attached to the traction ropes.

D.A small amount of clear, watery drainage is normal. This is the body's natural response to injury.

E. Movement of the pin at the insertion site is not an expected finding and may indicate inadequate stabilization or loosening of the pin. The pins should be securely anchored to the bone to maintain proper traction and stability.

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A patient who is receiving sustained-release morphine sulfate (MS Contin) every 12 hours for chronic pain experiences level 9 (0 to 10 scale) breakthrough pain and anxiety. Which action by the nurse is appropriate for treating this change in assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a client who has a fracture to achieve the outcome of functional healing. To assist in meeting this goal, which of the following nursing interventions is the highest priority?

Correct Answer is C

Explanation

A nurse is caring for a client who is postoperative and in skeletal traction. When assessing the client, the nurse should expect which of the following findings? (Select all that apply.)

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

Explanation

A nurse assessing a client who has multiple fractures in his left leg notes increasing edema. The nurse should recognize this finding as an early manifestation of which of the following complications?

Which of the following statements accurately describe the medication rights? (Select All that Apply.)

The nurse is caring for a patient who has diabetes and reports chronic, burning leg pain even when taking oxycodone (OxyContin) twice daily. Which prescribed medication is the best choice for the nurse to administer as an adjuvant to decrease the patient's pain?

A nurse is teaching a client who has a fractured femur about fat emboli syndrome. Which of the following findings should the nurse include as a manifestation of a fat embolism?

A disoriented and agitated patient comes to the emergency department and admits using methamphetamine. Vital signs are blood pressure 164/94 mm Hg. heart rate 136 beats/min and irregular, and respirations 32 breaths/min. Which action by the nurse is most important?

A nurse notes increasing edema in the calf of a client who has multiple fractures of the leg. The nurse should recognize that increasing edema is a manifestation of which of the following complications?

A nurse is providing care for four clients on a medical-surgical unit, Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)

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?