A nurse is caring for a client who has a fractured leg and rates their pain as 7 on a scale of 0 to 10. Which of the following medications should the nurse expect to administer?

Fentanyl

Aspirin

Hydrocodone

Acetaminophen

Answer and Explanation

The Correct Answer is C

Rationale:

A. Fentanyl: Fentanyl is a potent opioid typically reserved for severe, acute, or chronic pain such as in surgical or cancer-related conditions. It is not commonly used for moderate pain in stable orthopedic cases like a simple fracture.

B. Aspirin: Aspirin is a mild analgesic and anti-inflammatory. It may help with mild pain but is inadequate for moderate pain rated 7/10. Additionally, its antiplatelet effects can increase bleeding risk, especially post-trauma.

C. Hydrocodone: Hydrocodone is an opioid analgesic appropriate for managing moderate to severe pain, such as that caused by a fracture. It is commonly used in combination with acetaminophen and is suitable for a pain rating of 7/10.

D. Acetaminophen: Acetaminophen is effective for mild to moderate pain but may not provide sufficient relief for pain rated at 7/10. It is often used adjunctively but would not be the primary choice in this scenario.

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Correct Answer is D

Explanation

A. First trimester bleeding: Bleeding during the first trimester is more characteristic of conditions such as miscarriage or ectopic pregnancy. Abruptio placentae typically occurs in the third trimester and is not associated with early pregnancy bleeding.

B. Delayed menses: Delayed or missed menses is a sign of early pregnancy, not a complication of abruptio placentae, which occurs after the placenta has implanted and matured.

C. Nausea: Nausea is common in early pregnancy or with hyperemesis gravidarum but is not a hallmark symptom of abruptio placentae.

D. Severe abdominal pain: Sudden, severe, and continuous abdominal or lower back pain is a classic manifestation of abruptio placentae. It occurs due to premature separation of the placenta from the uterine wall, often accompanied by vaginal bleeding and uterine tenderness or rigidity.

A. Maintain the head of the client's bed at a 30° angle or higher. B. Change the feeding container and tubing every 24 hr. C. Ensure the formula is cold before administration. D. Check gastric residuals every 4 hr. E. Check placement of the feeding tube by x-ray once daily.

Correct Answer is ["A","B","D"]

Explanation

A. Maintain the head of the client's bed at a 30° angle or higher: Elevating the head of the bed to at least 30° reduces the risk of aspiration by preventing reflux of gastric contents into the airway, which is a critical safety measure during continuous enteral feedings.

B. This helps prevent bacterial contamination. For open systems, administration sets/tubing are typically changed every 24 hours (per manufacturer/facility policy).

C. Ensure the formula is cold before administration: Enteral formulas should be at room temperature before administration to prevent gastrointestinal discomfort and cramping. Cold formula can cause nausea, abdominal pain, and delayed gastric emptying.

D. Check gastric residuals every 4 hr: Monitoring gastric residuals every 4 hours helps assess feeding tolerance, detect delayed gastric emptying, and reduce the risk of aspiration. This is standard practice for continuous enteral feedings.

E. Check placement of the feeding tube by x-ray once daily: Tube placement should be confirmed by x-ray initially after insertion and as clinically indicated, not daily. Daily x-rays are unnecessary and expose the client to excessive radiation.

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A nurse is caring for a client who has a fractured leg and rates their pain as 7 on a scale of 0 to 10. Which of the following medications should the nurse expect to administer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an abruptio placentae. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

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