Patient Data

Exhibits

Based on the trending heart rate and pain score, what should the nurse do? Select all that apply.

Lead the client in guided imagery

Give a dose of 2.5 mg of Morphine

Assist the client to walk around the room

Assess for sources of pain other than the surgical site

Consult with the surgeon about the pain level

Answer and Explanation

Correct Answer : A,D,E

Choice A: Lead the client in guided imagery

This is a correct choice because guided imagery is a non-pharmacological intervention that can help reduce pain and anxiety by creating a relaxing mental image for the client. Guided imagery can also lower the heart rate and blood pressure by activating the parasympathetic nervous system.

Choice B: Give a dose of 2.5 mg of Morphine

This is an incorrect choice because morphine is an opioid analgesic that can cause respiratory depression, hypotension, and bradycardia. The client's heart rate is already elevated, which could indicate inadequate pain relief or anxiety. Giving more morphine could worsen the client's condition and mask the underlying cause of the pain.

Choice C: Assist the client to walk around the room

This is an incorrect choice because walking around the room could increase the client's pain and heart rate by stimulating the sympathetic nervous system. The client has already done ambulation exercises with physical therapy at 1200, so there is no need to repeat them at 1400. The client should be allowed to rest in bed and conserve energy.

Choice D: Assess for sources of pain other than the surgical site

This is a correct choice because the nurse should always assess the client holistically and rule out any other potential causes of pain, such as infection, inflammation, or ischemia. The nurse should also check the surgical site for any signs of bleeding, hematoma, or infection. The nurse should use a comprehensive pain assessment tool that includes the location, intensity, quality, duration, frequency, and aggravating and relieving factors of the pain.

Choice E: Consult with the surgeon about the pain level

This is a correct choice because the nurse should collaborate with the surgeon and other members of the health care team to provide optimal pain management for the client. The nurse should report the client's pain score, vital signs, medication administration, and response to interventions. The surgeon may order additional tests or medications to address the cause of the pain and improve the client's comfort.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A Reason: Massaging the injection site can cause bruising and bleeding, and is not recommended for subcutaneous heparin injections.

Choice B Reason: Rotating injections between different body sites can increase the risk of hematoma formation and skin irritation, and is not advised for subcutaneous heparin injections.

Choice C Reason: Expelling the air in the prefilled syringe can result in a loss of medication dose, and is not necessary for subcutaneous heparin injections.

Choice D Reason: Injecting in the abdominal area at least 2 inches from the umbilicus is the correct technique for subcutaneous heparin injections, as it reduces the risk of injury to blood vessels and nerves, and ensures consistent absorption of the medication.

Correct Answer is ["2.5"]

Explanation

To find the volume of the solution needed, the nurse can use the formula:

Volume (mL) = Dose (mg) / Concentration (mg/mL)

Substituting the given values, we get:

Volume (mL) = 1 mg / 0.4 mg/mL

Simplifying, we get:

Volume (mL) = 2.5 mL

Therefore, the nurse should administer 2.5 mL of naloxone to give a dose of 1 mg.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Patient Data Exhibits Based on the trending heart rate and pain score, what should the nurse do? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a client how to self-administer low-molecular-weight heparin subcutaneously. Which instruction should the nurse include?

Correct Answer is D

Explanation

The nurse plans to administer naloxone 1 mg. The label of the 10 mL vial indicates that the drug concentration is 0.4 mg/mL. How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

Correct Answer is ["2.5"]

Explanation

A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours as needed for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)

A client with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage?

The nurse observes that there are reddened areas on the cheekbones of a client receiving oxygen per nasal cannula at 3 L/minute, and the client's oxygen saturation level is 92%. Which intervention would the nurse implement?

The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the client’s foot in a basin of warm water placed on the bed. Which action should the nurse take?

Prior to initiating digital removal of a fecal impaction, it is most important for the nurse to perform which client assessment?

A female client assigned to a mental health unit visits with her significant other during the evening. After the significant other leaves, the nurse notices that the client is more isolative and refuses to attend the evening group. Which response by the nurse is most therapeutic?

After reviewing the admission assessment of a client with chronic pain, which intervention(s) should the nurse include in this client's plan of care? (Select all that apply.)

A male client with a nasogastric tube connected to low intermittent suction tells the nurse that his mouth is very dry. Which action should the nurse implement?

Patient Data

Exhibits

Based on the trending heart rate and pain score, what should the nurse do? Select all that apply.