A patient with a deep partial thickness burn has been receiving hydromorphone through patient-controlled analgesia (PCA) for 1 week. The nurse caring for the patient during the previous shift reports that the patient wakes up frequently during the night reporting pain. What action by the nurse is appropriate?

Teach the patient to push the button every 10 minutes for an hour before going to sleep, even if the pain is minimal.

Request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain.

Consult with the health care provider about using a different treatment protocol to control the patient's pain.

Administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping.

Answer and Explanation

The Correct Answer is C

C. This option is appropriate as the current treatment protocol is not effectively managing the patient's pain. The nurse can collaborate with the healthcare provider to reassess the patient's pain management needs and explore alternative strategies or adjustments to the PCA regimen.

A. This approach may lead to overmedication and increase the risk of adverse effects such as respiratory depression or sedation.

B. Requesting a bolus dose when the patient awakens with pain could be a part of the solution, but it should be carefully evaluated within the context of the overall pain management plan.

D. Administering scheduled doses of morphine from the PCA machine without the patient's input or based solely on time intervals is not recommended.

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Correct Answer is C

Explanation

A. This approach may lead to overmedication and increase the risk of adverse effects such as respiratory depression or sedation.

B. Requesting a bolus dose when the patient awakens with pain could be a part of the solution, but it should be carefully evaluated within the context of the overall pain management plan.

D. Administering scheduled doses of morphine from the PCA machine without the patient's input or based solely on time intervals is not recommended.

A. Apply lotion to the skin under the edges of the splint. B. Reposition the client to keep him from staying in the same position in bed. C. Remove the weights for a few minutes each hour. D. Apply a foot plate to the bed.

Correct Answer is B

Explanation

B. Repositioning the client regularly is an important intervention to prevent pressure ulcers and pressure points, especially when the client is immobilized in traction. Repositioning helps distribute pressure evenly on different areas of the body, reducing the risk of tissue ischemia and pressure-related injuries around the edges of the splint.

A. Lotions or moisturizers can increase the risk of skin breakdown and infection, especially when applied under medical devices such as splints or casts.

C. Removing the weights for a few minutes each hour is not necessary to prevent pressure points around the edges of the splint. Balanced skeletal traction is typically applied to maintain continuous traction force on the fractured femur for therapeutic purposes.

D. Applying a foot plate to the bed is not directly related to preventing pressure points around the edges of the splint. Foot plates are typically used to prevent foot drop and maintain proper alignment of the foot and ankle joints.

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is caring for a client who has a prescription for balanced skeletal traction with a Thomas splint for the treatment of a fractured femur. Which of the following interventions should the nurse implement to prevent pressure points from developing around the edges of the splint?

Correct Answer is B

Explanation

A nurse is teaching a client who is scheduled for dual-energy x-ray absorptiometry (DXA) to screen for osteoporosis. Which of the following instructions should the nurse include in the teaching?

An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which potential complication should the nurse identify as a priority for this patient?

A nurse is providing care for four clients on a medical-surgical unit, Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)

A nurse is teaching a newly licensed nurse about the difference between a plaster cast and a synthetic cast. Which of the following information should the nurse include in the teaching?

A nurse is caring for a client in the emergency department (ED). Exhibits Select the 4 assessment findings on day 2 that require immediate follow-up.

A nurse assessing a client who has multiple fractures in his left leg notes increasing edema. The nurse should recognize this finding as an early manifestation of which of the following complications?

A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs?