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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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.

A. Use a standard pain assessment tool B. Increase features of the scale, such as font size C. Repeat instructions and questions more than once D. Ask about present level of pain rather than pain history D. Ask about present level of pain rather than pain history E. Allow ample time for the patient to respond (Source: https://quizlet.com/129952120/pain-assessment-hesi-flash-cards/).

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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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has rheumatoid arthritis and has been prescribed ibuprofen (Advil). Which of the following instructions should the nurse include in the teaching? Select all that apply.

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

Explanation

The primary health care provider instructs the nurse to obtain the patient’s pain level every four hours. Which actions by the nurse help facilitate the pain assessment? Select all that apply.

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

Explanation

Which component of pain assessment is addressed by asking a client to rate his or her current level of discomfort on a scale of 0-10?

A nurse is caring for a patient who has been prescribed fentanyl patches for chronic cancer pain management at home. Which statement by the patient indicates that he understands how to use this medication safely?

A nurse is educating a client about ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), that has been prescribed for moderate pain and inflammation. Which of the following instructions should the nurse include? (Select all that apply.).

A nurse is caring for a client who has a sickle cell crisis and is receiving morphine via patient-controlled analgesia (PCA) pump. Which assessment finding indicates that the PCA pump is effective?

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?

A patient with cancer-related bone pain is receiving etidronate as an adjuvant analgesic. The nurse should monitor the patient for which of the following laboratory values?

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

A nurse is teaching a client who has cancer pain about the use of oral oxycodone with acetaminophen (Percocet). Which statement by the client indicates a need for further teaching?