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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Free Nursing Study Resources

Correct Answer is C

Explanation

C. A neurovascular assessment involves evaluating the circulation, sensation, and movement of the limb distal to the cast to ensure there are no signs of neurovascular compromise, such as decreased pulses, numbness, tingling, or weakness. Prompt identification of any neurovascular impairment is essential for preventing complications such as compartment syndrome.

A. Explaining discharge instructions is important for ensuring the client and their parents understand how to care for the cast at home. However, it is not the priority action.

B. Applying an ice pack to the casted leg can help reduce swelling and provide pain relief, but it is not the priority action immediately after the cast application.

D. Providing reassurance is important for alleviating anxiety and promoting a positive experience for the client and their parents. However, it is not the priority action.

A. The patient reports abdominal pain when ambulating. B. The patient has fluid intake 600 mL greater than the output. C. The patient's calf is swollen and warm to touch. D. The patient's temperature is 100.3° F (37.9° C).

Correct Answer is C

Explanation

C. The patient's calf being swollen and warm to touch is concerning for a possible deep vein thrombosis (DVT), a clot formation in the deep veins of the leg. DVT is a serious complication post-surgery that requires immediate attention to prevent the clot from dislodging and causing a pulmonary embolism (PE), which can be life-threatening.

A. Abdominal pain after a total abdominal hysterectomy is common and can be expected due to the surgical incision and manipulation of abdominal tissues.

B. Fluid balance is important postoperatively to prevent complications like dehydration or fluid overload. A significant imbalance, with intake substantially greater than output, could indicate issues which may require intervention. However, this is not as urgent as a client with likely DVT.

D. A slight increase in temperature is common in the immediate postoperative period due to the body's response to tissue injury. While it could indicate infection, it's not necessarily alarming on its own.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?

Correct Answer is C

Explanation

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?

Correct Answer is C

Explanation

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 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?

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?

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 teaching a client who is scheduled for dual-energy x-ray absorptiometry (DXA) to screen for osteoporosis. Which of the following instructions should the nurse include in the teaching?

Which medication is classified as an benzodiazepine?

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?

A nurse is caring for a client who has a cast in place for a fractured tibia. Which of the following nursing actions is the priority immediately after the provider has applied the cast?