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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Fractures, crush injuries, or tight casts can lead to compartment syndrome. Symptoms include severe pain, swelling, numbness or tingling, and decreased sensation or function of the affected limb.
Increasing edema in the calf is a hallmark manifestation of acute compartment syndrome and indicates a worsening of the condition.
A. Malignant hyperthermia is a rare but life-threatening complication that can occur in response to certain medications used during anesthesia. Edema in the calf is not a manifestation of malignant hyperthermia.
B. Pulmonary embolism occurs when a blood clot travels to the lungs and blocks blood flow. While pulmonary embolism can cause symptoms such as chest pain, shortness of breath, and cough, edema in the calf is not a typical manifestation of this condition.
C. Fat embolism syndrome occurs when fat globules are released into the bloodstream, often after long bone fractures or orthopedic procedures. Increasing edema in the calf is not a characteristic manifestation of fat embolism syndrome.
Correct Answer is A
Explanation
A. In the event of a life-threatening situation, the immediate priority is to address the situation to stabilize the client's condition. If removing the weights from the traction device is necessary to manage the life-threatening situation then the nurse may remove the weights as part of the overall management of the client's care.
B. It's generally not necessary to remove the weights from the traction device for an x-ray of the femur. Instead, the x-ray can typically be performed with the weights in place.
C. Pain management is important for clients in traction, but removing the weights is not the initial action for addressing pain. The nurse should assess the cause of the pain and intervene appropriately.
D. Repositioning the client in the bed may be necessary for comfort, preventing pressure ulcers, or facilitating care activities. When repositioning the client, the nurse should ensure that the traction setup remains intact and that the weights are properly secured.
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