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 ["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.

A. Begin full weight bearing. B. Apply heat to the affected knee. C. Start range of motion (ROM) exercises. D. Perform quadriceps setting exercises.

Correct Answer is D

Explanation

D. Quadriceps setting exercises help strengthen the quadriceps muscles, which play a crucial role in knee stability and function. These exercises can be initiated early in the postoperative period and are typically part of the rehabilitation program following a partial meniscectomy.

A. Full weight bearing may place excessive stress on the knee joint and hinder the healing process.

B. Heat therapy is generally not recommended immediately after a partial meniscectomy. Heat can increase blood flow and swelling, which may exacerbate pain and inflammation in the early postoperative period.

C. Range of motion (ROM) exercises help prevent stiffness and promote flexibility in the knee joint after surgery. However, these exercises should not be initiated immediately.

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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 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 in a one-day surgery center is providing discharge teaching for a client who is postoperative following a partial meniscectomy. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

A nurse is teaching a client who has a new prescription for cyclosporine oral solution to treat rheumatoid arthritis. Which of the following information should the nurse include in the teaching?

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 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?

The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider?

Which medication is classified as an benzodiazepine?

A nurse in a provider's office is assessing a client who reports shoulder pain. Which of the following findings by the nurse indicates rotator cuff injury?

The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon?

A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs?