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. Reporting any worsening or unrelieved pain is important because increasing or unrelieved pain could indicate complications such as inadequate immobilization, pressure sores, or compartment syndrome. Prompt reporting allows for timely intervention and prevention of further complications

B. Movement of the affected leg could disrupt the alignment of the bones and impede the healing process. Immobilization is essential for bone healing in a fiberglass cast. However, reporting features of compartment syndrome is priority.

C. Patients should be advised not to insert anything under the cast and instead use other methods such as blowing cool air under the cast or gently tapping on the outside of the cast to relieve itching.

D. Using a blow dryer on a moderate heat setting can help speed up the drying process of the cast after it gets wet. However, it's important to ensure that the heat is not too high to avoid causing burns or softening the cast material excessively.

A. Osteomyelitis B. Acute compartment syndrome C. Fat embolism syndrome D. Pulmonary embolism

Correct Answer is B

Explanation

B. Acute compartment syndrome occurs when increased pressure within a muscle compartment compromises circulation to the muscles and nerves within that compartment. Fractures, especially those accompanied by significant soft tissue injury or bleeding, can lead to compartment syndrome.

A Osteomyelitis is an infection of the bone that can occur as a complication of fractures, particularly if the fracture is open (the bone breaks through the skin). This occurs in the later courses of an infection.

C Fat embolism syndrome occurs when fat globules from fractured bones enter the bloodstream and become lodged in small blood vessels in organs such as the lungs, brain, and skin. Increasing edema is not an early sign of fat embolism.

D Pulmonary embolism (PE) is a serious condition where a blood clot travels to the lungs and blocks blood flow. While fractures, especially long bone fractures, can increase the risk of developing blood clots, increasing edema in the fractured limb is not typically an early sign of pulmonary embolism.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who has a fracture of the right tibia and a fiberglass cast. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

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?

Correct Answer is B

Explanation

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?

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.)

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 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 reviewing risk factors for osteoporosis with a group of nursing students. The nurse should include that which of the following types of medication therapy is a risk factor for osteoporosis?

The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I don't understand what the doctor said about the surgery." Which action should the nurse take next?

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?

A nurse is caring for a client who is 1-day postoperative following total hip arthroplasty. It is 0830 and the client is schedule for physical therapy (PT) at 0900. Which of the following interventions should the nurse take?