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A nurse is collecting data from a client who received IV morphine for postoperative pain. The nurse should identify that which of the following findings indicates a therapeutic response to the medication?

The client's blood pressure has been reduced.

The client exhibits diaphoresis

The client is not grimacing

The client has an elevated heart rate

Answer and Explanation

The Correct Answer is C

Answer: (C) The client is not grimacing

Rationale:

A) The client's blood pressure has been reduced:

While morphine can lower blood pressure due to its vasodilatory effects, a reduction in blood pressure is not necessarily a primary indicator of a therapeutic response to pain relief. It is more important to assess pain relief directly through the client's subjective experience and behavior rather than focusing on vital signs alone.

B) The client exhibits diaphoresis:

Diaphoresis, or sweating, can occur as a side effect of morphine administration but does not indicate that the medication is effectively relieving pain. In fact, diaphoresis might signal an adverse reaction or discomfort rather than a therapeutic effect.

C) The client is not grimacing:

The absence of grimacing suggests that the client's pain has decreased, which is a direct indicator of a therapeutic response to morphine. Observing a reduction in pain-related behaviors, such as grimacing, is a key assessment for determining the effectiveness of pain management in postoperative clients.

D) The client has an elevated heart rate:

An elevated heart rate may be a sign of unresolved pain or a side effect of morphine but is not a clear indicator of pain relief. Effective pain management with morphine typically results in a decrease in sympathetic nervous system responses, such as a high heart rate, rather than an increase.

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Correct Answer is A

Explanation

After a patient dies, postmortem care includes preparing them for family viewing . The nurse should place the body in the supine position, with the arms at the sides and the head on a pillow. Then elevate the head of the bed 30 degrees to prevent discoloration from blood setling in the face.

The other options are not correct because:

b) The nurse should cleanse the client's body while wearing appropriate personal protective equipment (PPE) based on indications for isolation precautions, not necessarily sterile gloves.

c) If the patient wore dentures and your facility’s policy permits, gently insert them; then close the mouth.

d) The nurse should close the eyes by gently pressing on the lids with their fingertips. If they don’t stay closed, place moist coton balls on the eyelids for a few minutes, and then try again to close them. Surgical tape is not mentioned as necessary .

A. Pallor in the exposed portion of the left foot. B. Inability to move the left foot. C. Increased warmth of the exposed portion of the left foot. D. Ecchymosis in the exposed portion of the left foot. E. e. Paresthesia in the left foot

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

Explanation

Compartment syndrome is a condition characterized by increased pressure within a closed anatomical space, such as a compartment in the leg. This increased pressure can compromise blood ﬂow and nerve function. When assessing a client with a long-leg cast who reports severe pain, the nurse should be vigilant for signs and symptoms of compartment syndrome.

Option a is a correct answer because pallor (paleness) in the exposed portion of the left foot may indicate compromised blood ﬂow due to increased pressure within the compartment.

Option b is a correct answer because the inability to move the left foot suggests impaired nerve function,

which can be a sign of compartment syndrome.

Option c is not a correct answer. Increased warmth is not typically associated with compartment syndrome; instead, it may suggest inﬂammation or infection.

Option d is not a correct answer. Ecchymosis (bruising) is not typically associated with compartment syndrome, as it is more commonly observed in cases of injury or trauma.

Option e is a correct answer because paresthesia (abnormal sensations like tingling or numbness) in the left foot can indicate nerve compression and is a potential symptom of compartment syndrome.

By identifying the presence of pallor, inability to move the foot, and paresthesia, the nurse can recognize indications of compartment syndrome and take appropriate actions to address the condition promptly.

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A nurse is collecting data from a client who received IV morphine for postoperative pain. The nurse should identify that which of the following findings indicates a therapeutic response to the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing postmortem care for a client prior to the family viewing the body. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has a long-leg cast on his left leg and reports severe pain. Which of the following findings should the nurse identify as an indication that the client might have compartment syndrome? (Select all that apply.)

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

Explanation

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