A client with acute pain is prescribed a sustained-release opioid that is administered every 12 hours. After 6 hours, the client complains of increasing pain that is rated as 9/10. Which intervention by the nurse is most appropriate to address the client's pain?

Teach the client a relaxation technique to use until the next dose is due.

Obtain an order for an immediate-release opioid for breakthrough pain.

Explain to the client that the medication being administered lasts for 12 hours.

Assess the client's vital signs and administer the next dose of opioids early.

Answer and Explanation

The Correct Answer is B

A. Teach the client a relaxation technique to use until the next dose is due: While relaxation techniques can be helpful in managing pain, they are not sufficient for severe pain rated 9/10. The client requires more immediate pharmacological intervention.
B. Obtain an order for an immediate-release opioid for breakthrough pain: This is the most appropriate action. Immediate-release opioids are specifically used to manage breakthrough pain in clients on sustained-release opioid therapy. It addresses the client's severe pain effectively and promptly.
C. Explain to the client that the medication being administered lasts for 12 hours: Simply explaining the duration of the medication does not address the client's current severe pain. Effective pain management requires action, not just education.
D. Assess the client's vital signs and administer the next dose of opioids early: Administering the next dose early can lead to inappropriate dosing schedules and potential overdose. It is important to follow the prescribed dosing regimen and manage breakthrough pain appropriately.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Review with the client and spouse when to notify the physician: Appropriate
Rationale: It is essential to inform the client and their spouse about signs and symptoms that would require notifying the physician, such as increased pain, fever, or unusual symptoms. This helps ensure the client can recognize and report any issues promptly.
Instruct the client to sign their advance directive form: Inappropriate
Rationale: Advance directive forms should be completed well before a surgical procedure and are not typically addressed at the time of discharge following a minor same-day surgery. This is not directly related to the immediate postoperative care and discharge instructions.
Discuss appropriate wound care: Appropriate
Rationale: Providing instructions on how to care for the wound is crucial for preventing infection and promoting proper healing. This information is essential for the client's recovery and should be reviewed before discharge.
Educate on activity limitations: Appropriate
Rationale: Informing the client about activity restrictions helps prevent complications and supports appropriate healing. This education is crucial for ensuring the client follows guidelines that will aid in their recovery.
Provide information about dietary restrictions: Appropriate
Rationale: Depending on the type of surgery and sedation, there may be dietary restrictions or guidelines to follow. Providing this information helps the client manage their diet appropriately after discharge.

A. Discontinue use of supplemental oxygen B. Encouraging use of incentive spirometer C. Implement fluid restrictions D. Administering an antitussive agent

Correct Answer is B

Explanation

A. Discontinue use of supplemental oxygen: This option is incorrect because supplemental oxygen is used to increase the oxygen levels in the blood, which is not directly related to addressing respiratory acidosis. In respiratory acidosis, the problem is primarily with the elimination of CO2 rather than oxygenation.
B. Encouraging use of incentive spirometer: This is the correct choice as using an incentive spirometer helps improve lung expansion and promotes alveolar ventilation, which aids in reducing CO2 levels in the blood, thereby addressing respiratory acidosis.
C. Implement fluid restrictions: This option is not suitable because fluid restrictions do not directly address the underlying issue of respiratory acidosis. Fluid restrictions might be necessary for other conditions, but they are not effective in correcting respiratory acid-base imbalances.
D. Administering an antitussive agent: This is incorrect because antitussive agents suppress cough reflexes, which can be counterproductive. In respiratory acidosis, coughing is often a protective mechanism to help clear secretions, so suppressing it may worsen the acid-base imbalance.

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A client with acute pain is prescribed a sustained-release opioid that is administered every 12 hours. After 6 hours, the client complains of increasing pain that is rated as 9/10. Which intervention by the nurse is most appropriate to address the client's pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Arterial blood gases on a postoperative client with pneumonia indicate the client is in respiratory acidosis. To best improve this acid-base imbalance, which intervention should the nurse implement?

Correct Answer is B

Explanation

To promote effective coughing, deep breathing, and ambulation in the postoperative client, what nursing action is most important?

A client is experiencing respiratory depression, constipation, nausea and vomiting, and hypotension after receiving pain medication. Which class of analgesics did this client most likely receive?

An unresponsive client was brought to the emergency room and had an arterial blood gas drawn. Ten minutes later, the laboratory calls with the following results: PaO2 74%, pH 7.22, PaCO2 85 mm Hg, and HCO3 23 mEq/L. The nurse interprets the results as indicating which imbalance?

The nurse is educating a group of student nurses about the different types of anesthesia. The student demonstrates an understanding of the teaching when they state that a client would maintain a gag reflex with what anesthesia?

A client with acute pain is prescribed a sustained-release opioid that is administered every 12 hours. After 6 hours, the client complains of increasing pain that is rated as 9/10. Which intervention by the nurse is most appropriate to address the client's pain?

Which of the following assessment findings should alert the nurse that a client's IV has infiltrated? (Select All That Apply)