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 ["A","B","C"]
Explanation
Choice A reason: This is a correct answer because heart failure is a condition in which the heart cannot pump enough blood to meet the body's needs. This can cause fluid retention and congestion in the lungs, kidneys, and other organs. Heart failure can also affect the thirst mechanism and the secretion of antidiuretic hormone, which can lead to reduced fluid intake and increased fluid loss. Therefore, heart failure can increase the risk of dehydration in older clients.
Choice B reason: This is a correct answer because nonfunctional impairments are limitations in the ability to perform activities of daily living, such as bathing, dressing, or toileting. Nonfunctional impairments can be caused by various factors, such as cognitive decline, mobility problems, or sensory loss. Nonfunctional impairments can affect the access to fluids, the awareness of thirst, or the ability to swallow. Therefore, nonfunctional impairments can increase the risk of dehydration in older clients.
Choice C reason: This is a correct answer because longitudinal furrows on the tongue are signs of dehydration in older clients. The tongue is a mucous membrane that can reflect the hydration status of the body. Dehydration can cause the tongue to lose its moisture and elasticity, and develop cracks or fissures along its length. Therefore, longitudinal furrows on the tongue can indicate dehydration in older clients.
Choice D reason: This is an incorrect answer because hypertension is not an issue that might put your client at risk for dehydration, but rather a complication of dehydration. Hypertension is the elevation of the blood pressure above the normal range, which can damage the blood vessels and increase the risk of cardiovascular disease. Hypertension can be caused by various factors, such as aging, obesity, smoking, stress, or kidney disease. Dehydration can also cause hypertension, as the loss of fluid can reduce the blood volume and increase the blood viscosity and concentration of sodium. Therefore, hypertension is not a risk factor for dehydration, but a consequence of dehydration.
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.
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