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
B. Postmenopausal vaginal bleeding is a common symptom of endometrial cancer. It is one of the most significant warning signs for this condition in older women, as it may indicate abnormal growth in the endometrial lining.
A. Bloating is more commonly associated with ovarian cancer and gastrointestinal issues rather than endometrial cancer specifically.
C. Feeling full quickly after eating is more indicative of ovarian cancer or other gastrointestinal problems.
D. Unexplained weight gain is not a typical primary symptom of endometrial cancer; it is less specific and can be associated with various other conditions.
Correct Answer is A
Explanation
A. A client with extreme muscle weakness on the affected side should use a cane or other assistive devices to aid in mobility and ensure safety. This intervention helps the client maintain stability and prevent falls.
B. The client with muscle weakness should use the unaffected hand for daily activities to ensure safety and improve functional outcomes. Using the affected hand may increase the risk of injury.
C. A soft diet and thickened liquids are generally recommended for clients with dysphagia, which is not specifically indicated in the context of muscle weakness due to a stroke.
D. Encouraging the client to complete all ADLs independently may not be feasible or safe due to the muscle weakness. Support and assistance with ADLs are likely needed.
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