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 ["A"]

Explanation

A. Protein-calorie malnutrition can lead to decreased tissue integrity and delayed wound healing, increasing the risk of pressure ulcer development due to compromised nutritional status.

B. Diabetes, especially when uncontrolled, can lead to poor circulation and neuropathy, which increases the risk of pressure ulcers. Hyperglycemia can also impair wound healing and compromise the immune response, further contributing to the risk.

C. Edema increases pressure on the skin and underlying tissues, impairing circulation and increasing the risk of pressure ulcers, especially in areas where there is constant pressure or friction against surfaces.

D. A client with postoperative delirium is not necessarily at risk of delirium.

E. A client post cardiac catheterization and already ambulating is not at risk of pressure sores

A. Administer lorazepam (Ativan) 1 mg orally. B. Offer immediate-release morphine 30 mg orally. C. Suggest the patient take amitriptyline 10 mg orally. D. Give Ibuprofen 400 to 800 mg orally.

Correct Answer is B

Explanation

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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Naxlex Comprehensive Predictor Exams

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.)

Correct Answer is ["A"]

Explanation

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?

Correct Answer is B

Explanation

The nurse is caring for a patient who has diabetes and reports chronic, burning leg pain even when taking oxycodone (OxyContin) twice daily. Which prescribed medication is the best choice for the nurse to administer as an adjuvant to decrease the patient's pain?

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