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 A

Explanation

A. In the event of a life-threatening situation, the immediate priority is to address the situation to stabilize the client's condition. If removing the weights from the traction device is necessary to manage the life-threatening situation then the nurse may remove the weights as part of the overall management of the client's care.

B. It's generally not necessary to remove the weights from the traction device for an x-ray of the femur. Instead, the x-ray can typically be performed with the weights in place.

C. Pain management is important for clients in traction, but removing the weights is not the initial action for addressing pain. The nurse should assess the cause of the pain and intervene appropriately.

D. Repositioning the client in the bed may be necessary for comfort, preventing pressure ulcers, or facilitating care activities. When repositioning the client, the nurse should ensure that the traction setup remains intact and that the weights are properly secured.

A. Cool extremities B. Positive Phalen's sign C. Positive Trousseau's sign D. Decreased radial pulse

Correct Answer is B

Explanation

B. Phalen's sign is a test for carpal tunnel syndrome. It is positive when the client experiences numbness, tingling, or pain in the median nerve distribution (especially the thumb, index finger, middle finger, and half of the ring finger) within 1 minute of wrist flexion.

A. Cool extremities are not typically associated with carpal tunnel syndrome. They may indicate issues related to circulation rather than compression of the median nerve.

C. Trousseau's sign is a test for latent tetany, which is associated with hypocalcemia. It involves inflating a blood pressure cuff on the upper arm and observing for carpal spasm. It is not a manifestation of carpal tunnel syndrome.

D. A decreased radial pulse may indicate vascular issues or compression of the radial artery, not carpal tunnel syndrome.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

A nurse in a provider's office is assessing a client who has wrist pain. Which of the following findings is a manifestation of carpal tunnel syndrome?

Correct Answer is B

Explanation

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?

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 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 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?

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

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 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 planning care for a client who is postoperative following a total hip arthroplasty. Which of the following interventions should the nurse include in the plan of care?