The nurse admits an older adult who had abdominal surgery. Admission vital signs are heart rate (pulse) (P), 73 beats per minute (bpm); respiration rate (R), 20 breaths per minute; blood pressure (BP), 136/84 mm Hg. He is receiving intravenous (IV) fluids but has not requested pain medication since surgery. Seven hours later, his vital signs are P, 98 bpm; R, 26 breaths per minute, and BP, 164/90 mm Hg and he denies pain. Which intervention should the nurse implement?
Ask if he has any discomfort at the surgical site or any other location.
Administer an opioid medication by IV route.
Check the surgical dressing for bleeding.
Report the vital signs to the health care provider.
The Correct Answer is A
Choice A reason: This is the correct answer because the nurse should assess the patient's pain level and location, even if he denies pain. The patient's vital signs indicate that he may be experiencing pain, as increased heart rate, respiration rate, and blood pressure are common physiological responses to pain. Pain can also be masked by other factors, such as fear, anxiety, or stoicism. Therefore, the nurse should ask the patient about his comfort and use a valid pain assessment tool, such as the numeric rating scale or the faces pain scale, to measure his pain intensity.
Choice B reason: This is incorrect because the nurse should not administer an opioid medication by IV route without assessing the patient's pain level and location first. Opioid medications are potent analgesics that can relieve severe pain, but they can also cause serious side effects, such as respiratory depression, sedation, nausea, vomiting, constipation, or dependence. The nurse should follow the principles of pain management, such as using the lowest effective dose, titrating the dose according to the patient's response, and monitoring the patient for adverse effects. The nurse should also consider using non-pharmacological interventions, such as ice packs, elevation, or distraction, to complement the pharmacological therapy.
Choice C reason: This is incorrect because the nurse should not check the surgical dressing for bleeding without assessing the patient's pain level and location first. Checking the surgical dressing for bleeding is an important intervention to monitor the patient's wound healing and prevent infection, but it is not the priority in this scenario. The nurse should first assess the patient's pain and provide appropriate pain relief, as pain can impair wound healing and increase the risk of complications. The nurse should also obtain the patient's consent and explain the procedure before checking the surgical dressing, as this can cause discomfort and anxiety.
Choice D reason: This is incorrect because the nurse should not report the vital signs to the health care provider without assessing the patient's pain level and location first. Reporting the vital signs to the health care provider is an important intervention to communicate the patient's condition and obtain further orders, but it is not the priority in this scenario. The nurse should first assess the patient's pain and provide appropriate pain relief, as pain can affect the vital signs and the patient's well-being. The nurse should also document the patient's pain assessment and intervention in the medical record, as this can facilitate the continuity of care and evaluation of outcomes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Performing all activities of daily living (ADLs) and then resting is not a good instruction for the older adult who has COPD, as it can cause fatigue, shortness of breath, and anxiety. The nurse would advise the older adult to pace themselves and prioritize the most important activities, and to take breaks between tasks.
Choice B reason: Bathing and eating slowly with periodic rest is a good instruction for the older adult who has COPD, as it can help conserve energy, prevent dyspnea, and improve digestion. The nurse would advise the older adult to use a shower chair or a handheld showerhead, to avoid hot water or steam, and to use a fan or an open window for ventilation. The nurse would also advise the older adult to eat small, frequent meals, to avoid foods that cause gas or bloating, and to drink fluids between meals rather than with them.
Choice C reason: Walking short distances without oxygen is not a safe instruction for the older adult who has COPD, as it can cause hypoxia, which is a low level of oxygen in the blood. The nurse would advise the older adult to use oxygen therapy as prescribed by their doctor, and to monitor their oxygen saturation with a pulse oximeter. The nurse would also advise the older adult to exercise regularly, but to start slowly and gradually increase the intensity and duration, and to stop if they feel dizzy, chest pain, or severe breathlessness.
Choice D reason: Bathing right after eating and then resting is not a helpful instruction for the older adult who has COPD, as it can cause indigestion, reflux, or aspiration. The nurse would advise the older adult to wait at least an hour after eating before bathing, and to avoid lying down right after eating or bathing. The nurse would also advise the older adult to elevate their head with pillows when resting or sleeping, and to avoid napping during the day.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A reason: Isolated systolic hypertension is not a result of end-organ damage from chronic hypertension, but rather a risk factor for it. Isolated systolic hypertension is a condition where the systolic blood pressure is elevated (>140 mmHg) while the diastolic blood pressure is normal (<90 mmHg). It is common in older adults due to the stiffening of the arteries, and can increase the risk of cardiovascular and cerebrovascular events.
Choice B reason: Atrial fibrillation is a result of end-organ damage from chronic hypertension. Atrial fibrillation is an irregular and often rapid heart rate that can cause poor blood flow and increase the risk of stroke and heart failure. Chronic hypertension can damage the heart muscle and the electrical system of the heart, leading to atrial fibrillation.
Choice C reason: Renal insufficiency is a result of end-organ damage from chronic hypertension. Renal insufficiency is a condition where the kidneys are unable to filter waste and fluid from the blood adequately. Chronic hypertension can damage the blood vessels and the nephrons of the kidneys, leading to renal insufficiency.
Choice D reason: Stroke is a result of end-organ damage from chronic hypertension. Stroke is a sudden interruption of blood supply to the brain, causing brain cell death and neurological deficits. Chronic hypertension can damage the blood vessels in the brain, making them prone to rupture (hemorrhagic stroke) or blockage (ischemic stroke).
Choice E reason: Cardiac disease is a result of end-organ damage from chronic hypertension. Cardiac disease is a broad term that encompasses various disorders of the heart, such as coronary artery disease, heart attack, heart failure, and cardiomyopathy. Chronic hypertension can damage the heart by increasing the workload and the oxygen demand of the heart, causing the heart to enlarge and weaken over time.
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