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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Decreased prothrombin time is not typically associated with the emergent phase of a burn injury. Prothrombin time changes are more related to liver function or coagulation disorders.
B. Increased hematocrit is common in the emergent/resuscitative phase of burn injury due to fluid shifts and loss of plasma volume, leading to hemoconcentration.
C. Increased sodium is not typically seen in the emergent phase; instead, hyponatremia may occur due to fluid shifts and loss of sodium in the burn exudate.
D. Potassium deficit is more likely to occur later in the burn management phases. In the emergent phase, hyperkalemia is more common due to cell destruction and release of intracellular potassium.
Correct Answer is A
Explanation
A. Cholelithiasis (gallstones) is a known risk factor for acute pancreatitis, as gallstones can block the bile duct and lead to inflammation of the pancreas.
B. Addison disease is not directly associated with an increased risk of acute pancreatitis. It primarily affects adrenal gland function.
C. Hypothyroidism does not typically influence the risk of developing acute pancreatitis. The condition primarily affects metabolism.
D. Gout is a condition related to elevated uric acid levels and is not a direct risk factor for acute pancreatitis.
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