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.)

Emphasize that their spouse may push the pain button when they are uncomfortable

Provide instructions on decreasing opioid doses by the second postoperative day.

Teach the patient about how analgesics improve postoperative activity levels.

Monitor for therapeutic and adverse effects of opioid administration.

Assess for signs that the patient is becoming addicted to the opioid.

Answer and Explanation

Correct Answer : C,D

C. Education about the benefits of pain management, including how analgesics can improve postoperative activity levels by reducing pain and discomfort, helps to promote the patient's understanding and engagement in their own care.

D. Nurses should closely monitor the patient for both therapeutic effects and adverse effects of opioid administration when using PCA or any other opioid analgesic. Regular assessment allows for prompt identification and management of any complications or side effects.

A. Patient-controlled analgesia (PCA) is designed for the patient to self-administer pain medication according to their own needs and pain levels.

B. Opioid dosing should be individualized based on the patient's pain level and response to the medication. Some patients may require ongoing opioid analgesia for more than two days postoperatively, while others may be able to transition to alternative pain management strategies sooner.

E. Concerns about opioid addiction should not be assumed in all patients, especially those who have never received opioids before. Instead, the focus should be on assessing the patient's pain levels, response to pain medication, and any adverse effects.

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Correct Answer is B

Explanation

B. Muscle spasms can sometimes be triggered or exacerbated by poor positioning or pressure on certain areas of the body. Realigning the client's position will help relieve muscle spasms by reducing pressure or tension on the affected muscles.

A. Adjusting the weight amount in traction may help alleviate pain and muscle spasms by reducing tension on the affected limb. However, realignment should be done first.

C. Muscle relaxants can help alleviate muscle spasms and associated pain by reducing muscle tone and tension. However, realignment should be done first.

D. Opioid analgesics are potent pain relievers that can effectively manage moderate to severe pain, including pain from muscle spasms. However, that should not be the first intervention.

A. "I will limit my fluid intake to 1 liter per day." B. "I will limit my alcohol intake." C. "I will take one aspirin every day." D. "I will closely follow a high-purine diet."

Correct Answer is B

Explanation

B. Alcohol consumption, especially beer and spirits, is associated with an increased risk of gout attacks as it can elevate uric acid levels in the body. Limiting alcohol intake can help prevent gout attacks.

A. While adequate hydration is important for overall health, limiting fluid intake to 1 liter per day may not be appropriate, especially considering that hydration can help prevent gout attacks.

C. While aspirin is commonly used for pain relief, it is not typically recommended for gout management.

D. High-purine foods such as red meat, organ meats, and certain seafood can exacerbate gout symptoms by increasing uric acid levels in the body. Therefore, closely following a high-purine diet would likely worsen gout symptoms rather than improve them.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

A nurse is completing discharge instructions with a client following an acute onset of gout. Which of the following client statements indicates an understanding of the treatment regimen?

Correct Answer is B

Explanation

A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching?

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

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

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?

A nurse is teaching a client about risk factors for osteoarthritis. Which of the following factors should the nurse include in the teaching? (Select all that apply.)

An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which potential complication should the nurse identify as a priority for this patient?