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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
The correct answer is choiceA,B , andD.
Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastric irritation and bleeding.Therefore, the nurse should instruct the client to take ibuprofen with food or milk to reduce the risk of stomach ulcers.The nurse should also advise the client to avoid alcohol while taking ibuprofen, as alcohol can increase the risk of gastrointestinal bleeding and liver damage.Additionally, the nurse should tell the client to report any signs of gastrointestinal bleeding, such as black or tarry stools, abdominal pain, or vomiting blood, to the healthcare provider immediately.
ChoiceCis wrong because taking ibuprofen on an empty stomach can increase the risk of gastric irritation and bleeding.
ChoiceEis wrong because taking ibuprofen with antacids can reduce the effectiveness of ibuprofen and interfere with its absorption.Antacids can also cause adverse effects such as diarrhea, constipation, or electrolyte imbalance.
Therefore, the nurse should not recommend taking ibuprofen with antacids.
Correct Answer is ["A","B","C","E"]
Explanation
The correct answer is choice A, B, C and E.These actions by the nurse help facilitate the pain assessment by using a consistent and clear method to measure the patient’s pain level, enhancing the visibility and understanding of the scale, repeating the information for clarity and accuracy, and giving the patient enough time to respond without rushing or interrupting.
Choice D is wrong because asking about the present level of pain rather than the pain history is more relevant for pain management, not the pain assessment.The pain history provides valuable information about the onset, duration, frequency, quality, intensity, location, and aggravating or relieving factors of the pain.
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