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
Explanation
Choice A reason: Demonstrating commitment to the special needs of the geriatric client by means of board-certification is the primary purpose of geriatric nursing certifications, as it shows that the nurse has met the standards of knowledge, skills, and practice in the field of gerontology. Board-certification also indicates that the nurse is dedicated to providing quality care and improving outcomes for the older adult population.
Choice B reason: Raising the level of professionalism for the geriatric facility is not the primary purpose of geriatric nursing certifications, as it is a secondary benefit that may result from having certified nurses on staff. Professionalism is not only determined by the credentials of the nurses, but also by their attitudes, behaviors, and values.
Choice C reason: Assuring the basic competency of the geriatric nurse is not the primary purpose of geriatric nursing certifications, as it is a minimum requirement that should be met by all nurses who work with older adults. Competency is not only measured by passing an exam, but also by demonstrating clinical judgment, ethical decision-making, and lifelong learning.
Choice D reason: Addressing the current shortage of specialized geriatric nurses is not the primary purpose of geriatric nursing certifications, as it is a challenge that cannot be solved by certifications alone. The shortage of geriatric nurses is influenced by many factors, such as the aging population, the lack of interest and incentives, and the high turnover and burnout rates.
Choice E reason: None of the above is not the correct answer, as there is one choice that is the primary purpose of geriatric nursing certifications.
Correct Answer is D
Explanation
Choice A reason: Position the client to achieve their comfort is not the most important intervention, as it does not address the potential risks of opioid analgesics, such as respiratory depression, sedation, and falls. Comfort is important, but not the priority in this situation.
Choice B reason: Offer toileting and a sip of water is not the most important intervention, as it does not address the potential risks of opioid analgesics, such as respiratory depression, sedation, and falls. Toileting and hydration are important, but not the priority in this situation.
Choice C reason: Place side rails up x 4 is not the most important intervention, as it may not prevent the client from getting out of bed and falling. Side rails may also be considered a restraint, which can increase the risk of injury and agitation. Side rails are not a substitute for proper supervision and assistance.
Choice D reason: Instruct the client to ask for help before getting up is the most important intervention, as it can prevent the client from falling and injuring themselves. Opioid analgesics can impair the client's balance, coordination, and judgment, making them more prone to falls. The nurse should educate the client about the effects of opioids and the importance of asking for help before attempting to get out of bed.
Choice E reason: None of the above is not the correct answer, as there is one choice that is the most important intervention for the nurse to implement before leaving the client’s room.
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