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","C","E"]
Explanation
The correct answer is choice A, B, C and E.Aspirin is a medication that can prevent cardiovascular events by inhibiting platelet aggregation and reducing inflammation.
However, aspirin also has some side effects that the patient should be aware of and report to the doctor if they occur.
Choice A is correct because taking aspirin with food or milk can reduce the risk of stomach irritation and ulcers that aspirin can cause.
Choice B is correct because aspirin can increase the risk of bleeding and bruising due to its antiplatelet effect.The patient should monitor for signs of bleeding such as black, tarry stools, bloody or cloudy urine, vomiting of blood or material that looks like coffee grounds, and unusual bleeding or bruising.
Choice C is correct because taking other NSAIDs (nonsteroidal anti-inflammatory drugs) concurrently with aspirin can increase the risk of stomach ulcers and bleeding.
NSAIDs include ibuprofen, naproxen, diclofenac, and others.
Choice D is wrong because tinnitus (ringing in the ears) is a sign of aspirin toxicity and should not be ignored.The patient should stop taking aspirin and seek medical attention if they experience tinnitus, confusion, hallucinations, rapid breathing, or seizures.
Choice E is correct because enteric-coated tablets can reduce the gastric irritation caused by aspirin by delaying its release until it reaches the small intestine.However, enteric-coated tablets may not be as effective as regular tablets in preventing cardiovascular events.
Correct Answer is A
Explanation
The correct answer is choice A. Avoid driving while taking this medication.The nurse should instruct the client to avoid driving or operating heavy machinery while taking acetaminophen and hydrocodone (Vicodin) because these medications can cause drowsiness, dizziness, and impaired mental function.The nurse should also warn the client about the risk of addiction, overdose, and death from misuse of this medication.
Choice B is wrong because taking this medication on an empty stomach can increase the risk of nausea and vomiting.The nurse should advise the client to take this medication with food or milk to prevent stomach upset.
Choice C is wrong because increasing the intake of foods rich in vitamin K is not relevant to taking acetaminophen and hydrocodone (Vicodin).Vitamin K is involved in blood clotting and may interact with some anticoagulant medications, but not with this medication.
Choice D is wrong because limiting fluid intake to prevent fluid retention is not necessary for a client taking acetaminophen and hydrocodone (Vicodin).This medication does not cause fluid retention or edema.The nurse should encourage the client to drink plenty of fluids to prevent constipation, which is a common side effect of opioid medications.
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