A patient with a deep partial thickness burn has been receiving hydromorphone through patient-controlled analgesia (PCA) for 1 week. The nurse caring for the patient during the previous shift reports that the patient wakes up frequently during the night reporting pain. What action by the nurse is appropriate?

Teach the patient to push the button every 10 minutes for an hour before going to sleep, even if the pain is minimal.

Request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain.

Consult with the health care provider about using a different treatment protocol to control the patient's pain.

Administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping.

Answer and Explanation

The Correct Answer is C

C. This option is appropriate as the current treatment protocol is not effectively managing the patient's pain. The nurse can collaborate with the healthcare provider to reassess the patient's pain management needs and explore alternative strategies or adjustments to the PCA regimen.

A. This approach may lead to overmedication and increase the risk of adverse effects such as respiratory depression or sedation.

B. Requesting a bolus dose when the patient awakens with pain could be a part of the solution, but it should be carefully evaluated within the context of the overall pain management plan.

D. Administering scheduled doses of morphine from the PCA machine without the patient's input or based solely on time intervals is not recommended.

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Correct Answer is A

Explanation

A. Vital sign monitoring every 15 minutes is a standard practice in the postanesthesia care unit (PACU) to closely monitor the patient's hemodynamic status and response to anesthesia. However, in this scenario, the patient's blood pressure (BP) and other vital signs are within an acceptable range, and there are no signs of instability.

B. The patient's vital signs, including BP, pulse rate, and skin condition, are within normal limits. There are no indications of hemodynamic instability or adverse events.

C. There is no indication to increase the postoperative intravenous (IV) fluid rate based solely on the patient's stable vital signs and absence of signs of dehydration or hypovolemia. Increasing IV fluids without clinical indication may lead to fluid overload and potential complications.

D. The patient's oxygen saturation level is not provided in the scenario, and there are no signs or symptoms of respiratory distress or hypoxemia. Therefore, administering oxygen therapy at 100% per mask is not warranted at this time.

A. A patient who had a tonsillectomy one week ago B. A patient who had a knee replacement surgery this morning C. A patient who had a hernia repair surgery yesterday D. A patient who had an appendectomy two days ago

Correct Answer is D

Explanation

D. Appendectomy is a common surgical procedure to remove the appendix and is considered a moderate surgical intervention. Early ambulation is generally encouraged for patients after appendectomy to prevent complications such as pneumonia, deep vein thrombosis, and ileus.

B. Knee replacement surgery is a major orthopedic procedure that requires early mobilization and rehabilitation to prevent complications such as blood clots, joint stiffness, and muscle weakness. However, the client needs more time before ambulation is initiated

A. Tonsillectomy is a relatively minor surgical procedure that typically does not significantly impact a patient's mobility or ability to ambulate. The patient who had a tonsillectomy one week ago is likely well-recovered and may not require immediate prioritization for ambulation.

C. Hernia repair surgery is typically considered a moderate surgical procedure. While early mobilization is generally beneficial for patients recovering from hernia repair surgery, it may not be as urgent as for patients undergoing major orthopedic surgeries like knee replacement.

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Naxlex Comprehensive Predictor Exams

A patient is admitted to the postanesthesia care unit (PACU) with a blood pressure (BP) 122/72 mm Hg. Thirty minutes after admission, the BP is 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate?

Correct Answer is A

Explanation

A post-operative patient is scheduled for ambulation. Which of the following patients should be prioritized for ambulation?

Correct Answer is D

Explanation

A nurse is assessing a client who has a hip fracture. Which of the following findings should the nurse expect?

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?

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?

A nurse is caring for a client who is 1-day postoperative following spinal fusion. Which of the following actions should the nurse take?

A nurse is caring for a client who has a fractured tibia as a result of a fall. The client x-ray shows that the bone is splintered into several pieces around the shaft. The nurse should identify that the client has which of the following types of fractures?

A nurse is assessing a client who is in skeletal traction. The nurse should correct which of the following findings?

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 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?