A nurse is caring for a 38-year-old client who presents to the emergency department (ED) in pain.
For each potential healthcare provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.
Intravenous fluid administration
Ice packs to affected area 15 min on/15 min off
Ambulation in hallway with supervision
Hydromorphone intravenously (IV) for pain
Acetaminophen orally (PO) for pain
Oxygen 2 L/min via nasal cannula
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}
Intravenous fluid administration is anticipated as hydration can help reduce the viscosity of sickled cells, improving circulation and potentially reducing vaso-occlusive events.
Ice packs to the affected area are nonessential and could potentially be contraindicated, as cold can cause vasoconstriction and may exacerbate pain.
Ambulation is nonessential during acute pain episodes and should be encouraged when the patient is comfortable and pain is controlled.
Hydromorphone IV for pain is anticipated because it is a stronger opioid than morphine and may be necessary if the pain is unresponsive to oral morphine sulfate.
Acetaminophen PO for pain is nonessential in this scenario as it is unlikely to provide adequate pain relief for severe vaso-occlusive pain.
Oxygen therapy is nonessential given the client's SpO2 is 95% on room air, indicating adequate oxygen saturation; however, it may be considered if there is evidence of hypoxia or respiratory distress. It is crucial to monitor the client's response to pain management interventions and adjust the treatment plan accordingly.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A face shield is necessary when there is a risk of splashes, but not required for simply checking a pulse.
B. Clean gloves are appropriate for contact with the client or the wound, as MRSA is transmitted through direct contact. This prevents contamination while assessing the client.
C. Sterile gloves are not required for checking a pulse unless performing a sterile procedure.
D. An N95 respirator mask is used for airborne precautions, not necessary for MRSA, which is contact-transmitted.
Correct Answer is D
Explanation
A. Vasopressin does not typically increase the client's heart rate; its primary effect is on the kidneys and urine output.
B. Vasopressin generally increases blood pressure by promoting vasoconstriction, not decreases it.
C. Vasopressin will increase, not decrease, urine specific gravity by reducing urine output and concentrating the urine.
D. Vasopressin acts to decrease urine output by increasing water reabsorption in the kidneys, which helps manage diabetes insipidus.
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