A patient who is receiving sustained-release morphine sulfate (MS Contin) every 12 hours for chronic pain experiences level 9 (0 to 10 scale) breakthrough pain and anxiety. Which action by the nurse is appropriate for treating this change in assessment?

Administer lorazepam (Ativan) 1 mg orally.

Offer immediate-release morphine 30 mg orally.

Suggest the patient take amitriptyline 10 mg orally.

Give Ibuprofen 400 to 800 mg orally.

Answer and Explanation

The Correct Answer is B

B. Immediate-release morphine provides rapid pain relief and can effectively address breakthrough pain. The dose of 30 mg is reasonable given the severity of the pain.

A. Lorazepam is a benzodiazepine used to treat anxiety. While it may help with anxiety, it does not directly address the severe breakthrough pain experienced by the patient.

C. Amitriptyline is a tricyclic antidepressant used to treat neuropathic pain and depression. While it may help with chronic pain management, it is not appropriate for providing rapid relief for breakthrough pain or acute anxiety.

D. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) commonly used for mild to moderate pain relief and inflammation. However, it is not typically used for severe breakthrough pain, especially in a patient already receiving opioid therapy.

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

Explanation

A. Assessing the temperature of the affected extremity is important because changes in temperature could indicate circulation problems, which are a concern with traction. Assessing temperature helps in detecting any potential issues early on.

C. Skin integrity is crucial as traction can put pressure on the skin, potentially leading to pressure ulcers or skin breakdown. Regular examination helps in detecting any signs of skin irritation or breakdown early so that appropriate interventions can be initiated.

D. Traction can sometimes impede circulation to the affected limb, leading to complications such as compartment syndrome. Monitoring peripheral pulses helps in detecting any circulation problems promptly.

B. Adjusting the prescribed weights is not typically within the nurse's scope of practice, as the weights are determined by the physician and should not be altered without specific orders.

E. Positioning the weights against the foot of the bed is incorrect; they should hang freely to maintain effective traction.

A. Continue to take vital signs every 15 minutes. B. Notify the anesthesia care provider (ACP). C. Increase the postoperative IV fluid rate. D. Administer oxygen therapy at 100% per mask.

Correct Answer is A

Explanation

A. Vital sign monitoring every 15 minutes is a standard practice in the postanesthesia care unit (PACU) to closely monitor the patient's hemodynamic status and response to anesthesia. However, in this scenario, the patient's blood pressure (BP) and other vital signs are within an acceptable range, and there are no signs of instability.

B. The patient's vital signs, including BP, pulse rate, and skin condition, are within normal limits. There are no indications of hemodynamic instability or adverse events.

C. There is no indication to increase the postoperative intravenous (IV) fluid rate based solely on the patient's stable vital signs and absence of signs of dehydration or hypovolemia. Increasing IV fluids without clinical indication may lead to fluid overload and potential complications.

D. The patient's oxygen saturation level is not provided in the scenario, and there are no signs or symptoms of respiratory distress or hypoxemia. Therefore, administering oxygen therapy at 100% per mask is not warranted at this time.

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A patient who is receiving sustained-release morphine sulfate (MS Contin) every 12 hours for chronic pain experiences level 9 (0 to 10 scale) breakthrough pain and anxiety. Which action by the nurse is appropriate for treating this change in assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take? (Select all that apply.)

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

Explanation

A patient is admitted to the postanesthesia care unit (PACU) with a blood pressure (BP) 122/72 mm Hg. Thirty minutes after admission, the BP is 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate?

Correct Answer is A

Explanation

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