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?
“I should drink plenty of fluids and eat high-fiber foods to prevent constipation.”
“I should avoid driving or operating heavy machinery while taking this medication.”
“I should take this medication only when I have severe pain that does not respond to other drugs.”
“I should report any signs of an allergic reaction, such as rash, itching, or difficulty breathing.”.
The Correct Answer is C
The correct answer is choice C. The client should take this medication regularly as prescribed to maintain a steady level of analgesia and prevent breakthrough pain.
Taking the medication only when the pain is severe can lead to inadequate pain relief and increased side effects.
Choice A is wrong because drinking plenty of fluids and eating high-fiber foods can help prevent constipation, which is a common adverse effect of opioids.
Choice B is wrong because avoiding driving or operating heavy machinery is a safety precaution for clients taking opioids, as they can cause drowsiness and impaired judgment.
Choice D is wrong because reporting any signs of allergic reaction is an important instruction for clients taking any medication, especially opioids, which can cause severe hypersensitivity reactions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. Serum bilirubin.The nurse should monitor the client’s serum bilirubin level closely because acetaminophen, a non-opioid analgesic, can cause hepatotoxicity and acute liver failure in cases of overdose.
Serum bilirubin is a marker of liver function and damage.
A high level of serum bilirubin indicates jaundice, a sign of liver injury.
Choice A is wrong because serum creatinine is a marker of kidney function and damage.Acetaminophen has limited nephrotoxicity compared to NSAIDs.
Choice B is wrong because serum potassium is not directly affected by acetaminophen.
Serum potassium is an electrolyte that reflects fluid and acid-base balance in the body.
Choice C is wrong because serum albumin is a protein that is synthesized by the liver.
Although serum albumin may be low in chronic liver disease, it is not a sensitive indicator of acute liver injury caused by acetaminophen overdose.
Normal ranges for serum bilirubin are 0.3 to 1.2 mg/dL for adults and 1 to 12 mg/dL for newborns.
Normal ranges for serum creatinine are 0.6 to 1.2 mg/dL for men and 0.5 to 1.1 mg/dL for women.
Normal ranges for serum potassium are 3.5 to 5 mEq/L for adults and children.
Normal ranges for serum albumin are 3.4 to 5.4 g/dL for adults and children.
Correct Answer is ["A","B","C","E"]
Explanation
The correct answer is choice A, B, C, and E. The nurse should use the following strategies to assess this client’s pain:
• Ask yes or no questions: This can help the client to communicate their pain level and location with minimal language difficulty.
• Use a visual analog scale (VAS): This is a self-report pain scale that uses a line with endpoints labeled as “no pain” and “worst pain imaginable”.The client can point to a position on the line that corresponds to their pain intensity.VAS has been shown to be feasible, valid, and reliable for stroke patients with mild-to-moderate aphasia.
• Observe for nonverbal cues: This can include facial expressions, body movements, vocalizations, and changes in vital signs that may indicate pain.Nonverbal cues are especially important for clients with severe aphasia who cannot use self-report scales.
• Involve family members or caregivers: They can provide information about the client’s pain history, preferences, and behaviors that may indicate pain.They can also help the nurse to communicate with the client and interpret their responses.
Choice D is wrong because open-ended questions require more complex language skills and may frustrate the client with aphasia.The nurse should use simple and direct questions that can be answered with yes or no, gestures, or pointing.
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