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 ["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.

A. Hepatic necrosis B. Pulmonary fibrosis C. Pancreatitis D. Cardiac dysrhythmias.

Correct Answer is A

Explanation

The correct answer is choice A. Hepatic necrosis.Acetaminophen (APAP) is a common cause of drug-induced liver injury and can lead to hepatic necrosis, especially in patients who have chronic hepatitis C.APAP is metabolized by the liver and produces a toxic intermediate called N-acetyl-p-benzoquinone imine (NAPQI), which can deplete glutathione and damage hepatocytes.Patients who have chronic hepatitis C may have reduced glutathione levels and increased oxidative stress, making them more susceptible to APAP toxicity.

Choice B. Pulmonary fibrosis is wrong because APAP does not cause pulmonary fibrosis.

Pulmonary fibrosis is a chronic lung disease that involves scarring of the lung tissue and impaired gas exchange.Some drugs that can cause pulmonary fibrosis are amiodarone, bleomycin, methotrexate and nitrofurantoin.

Choice C. Pancreatitis is wrong because APAP does not cause pancreatitis.

Pancreatitis is an inflammation of the pancreas that can result from gallstones, alcohol abuse, hypertriglyceridemia, hypercalcemia, infections, trauma or certain medications.

Some drugs that can cause pancreatitis are azathioprine, valproic acid, didanosine and pentamidine.

Choice D. Cardiac dysrhythmias is wrong because APAP does not cause cardiac dysrhythmias.

Cardiac dysrhythmias are abnormal heart rhythms that can result from electrolyte imbalances, ischemia, myocardial infarction, heart failure, congenital defects or certain medications.

Some drugs that can cause cardiac dysrhythmias are digoxin, quinidine, sotalol and erythromycin.

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Naxlex Comprehensive Predictor Exams

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

A nurse is caring for a client who has chronic hepatitis C and reports taking acetaminophen daily for headaches.The nurse should monitor the client for which of the following adverse effects?

Correct Answer is A

Explanation

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 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.)

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 is receiving epidural analgesia with buprenorphine (Buprenex). Which assessment finding would indicate that an adverse effect may be occurring?

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?

(Select all that apply) A patient with postoperative pain is prescribed hydroxyzine as an adjuvant analgesic. The nurse should teach the patient about which of the following benefits of this medication.