A nurse is caring for a patient who reports pain in his left leg that he rates as an 8 on a scale from 0 to 10 and states that he feels tingling and numbness in his toes.

The patient has an order for morphine sulfate 2 mg IV bolus PRN every two hours for pain greater than 7, last administered three hours ago, and ibuprofen 400 mg PO PRN every four hours for pain less than or equal to 7, last administered six hours ago.

What action should the nurse take first?

Administer morphine sulfate 2 mg IV bolus.

Administer ibuprofen 400 mg PO.

Assess the patient’s leg for circulation, sensation, and movement.

Reassess the patient’s pain in 15 minutes.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Assess the patient’s leg for circulation, sensation, and movement.

This is because the patient’s symptoms of pain, tingling, and numbness in his left leg could indicate a potential complication of impaired blood flow or nerve damage after surgery. The nurse should prioritize assessing the patient’s leg for any signs of compromised circulation, sensation, or movement before administering any pain medication.

Choice A is wrong because administering morphine sulfate 2 mg IV bolus without assessing the patient’s leg could mask the symptoms of a serious problem and delay appropriate interventions. Morphine sulfate is a potent opioid analgesic that can cause respiratory depression, sedation, and constipation.

Choice B is wrong because administering ibuprofen 400 mg PO without assessing the patient’s leg could also mask the symptoms of a serious problem and delay appropriate interventions. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastrointestinal bleeding, renal impairment, and increased risk of cardiovascular events.

Choice D is wrong because reassessing the patient’s pain in 15 minutes without assessing the patient’s leg could result in the worsening of the patient’s condition and increased risk of complications. The nurse should not delay assessing the patient’s leg for any signs of impaired circulation, sensation, or movement.

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Free Nursing Study Resources

Correct Answer is ["B","C"]

Explanation

The correct answer is choice B and C.Oxycodone (OxyContin) is a potent opioid analgesic that can causeconstipation,drowsiness,nausea,pruritus, andvomitingas common side effects.

To prevent constipation, the patient should be encouraged to drink plenty of fluids and eat high-fiber foods.To prevent respiratory depression and sedation, the patient should be advised to avoid alcohol and other CNS depressants while taking oxycodone.

Choice A is wrong because monitoring vital signs regularly is not specific to oxycodone use, but rather a general nursing intervention for any patient with chronic pain.

Choice D is wrong because acetaminophen (Tylenol) can interact with oxycodone and increase the risk of liver damage.

The patient should not take any other pain medications without consulting the prescriber.

Choice E is wrong because a patient-controlled analgesia (PCA) pump is not used for long-term pain management, but rather for acute or postoperative pain.Oxycodone (OxyContin) is formulated as an extended-release tablet that provides sustained pain relief for up to 12 hours.

A. Serum creatinine B. Serum potassium C. Serum albumin D. Serum bilirubin.

Correct Answer is D

Explanation

The correct answer is choice D. Serum bilirubin.The nurse should monitor the client’s serum bilirubin level closely because acetaminophen, a non-opioid analgesic, can cause hepatotoxicity and acute liver failure in cases of overdose.

Serum bilirubin is a marker of liver function and damage.

A high level of serum bilirubin indicates jaundice, a sign of liver injury.

Choice A is wrong because serum creatinine is a marker of kidney function and damage.Acetaminophen has limited nephrotoxicity compared to NSAIDs.

Choice B is wrong because serum potassium is not directly affected by acetaminophen.

Serum potassium is an electrolyte that reflects fluid and acid-base balance in the body.

Choice C is wrong because serum albumin is a protein that is synthesized by the liver.

Although serum albumin may be low in chronic liver disease, it is not a sensitive indicator of acute liver injury caused by acetaminophen overdose.

Normal ranges for serum bilirubin are 0.3 to 1.2 mg/dL for adults and 1 to 12 mg/dL for newborns.

Normal ranges for serum creatinine are 0.6 to 1.2 mg/dL for men and 0.5 to 1.1 mg/dL for women.

Normal ranges for serum potassium are 3.5 to 5 mEq/L for adults and children.

Normal ranges for serum albumin are 3.4 to 5.4 g/dL for adults and children.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient who has chronic low back pain is prescribed oxycodone (OxyContin) for long-term use. Which of the following interventions should the nurse implement to prevent complications from this medication? (Select all that apply.)

Correct Answer is ["B","C"]

Explanation

The nurse is caring for a client who has been prescribed acetaminophen, a non-opioid analgesic, for mild pain. Which laboratory test result should the nurse monitor closely in this client?

Correct Answer is D

Explanation

Which statement made by a client taking aspirin indicates an understanding of its use?

A nurse is teaching a client who has chronic pain about nonpharmacological pain management techniques. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.).

A nurse is providing discharge teaching to a client who has a prescription for acetaminophen and hydrocodone (Vicodin).Which of the following instructions should the nurse include in the teaching?

The nurse is preparing to administer morphine sulfate, an opioid analgesic, to a client who reports pain at level 8 on a scale of 0 to 10. Which action should the nurse take first?

A patient who is addicted to heroin is admitted to the hospital for treatment of an infection. The patient is prescribed methadone (Dolophine) as part of a detoxification program. What is the rationale for using methadone in this patient?

A patient with chronic back pain is prescribed gabapentin as an adjuvant analgesic. The nurse should instruct the patient to report which of the following adverse effects?

A nurse is reviewing laboratory results for a client who takes acetaminophen for osteoarthritis pain management.Which of the following findings should alert the nurse to possible hepatotoxicity? (Select all that apply.).