An older adult admitted for back surgery asks for opioid pain medication. The nurse knows the client asks for pain medication 30 minutes before it is due. Which recommendation should the nurse implement?

Teach the client alternative comfort measures

Tell the client that it is too soon for pain medication

Administer the pain medication as requested by the client

Validate the pain with other assessment data

Answer and Explanation

The Correct Answer is D

Choice A reason: Teaching the client alternative comfort measures is not the best recommendation for the nurse to implement, as it may imply that the client's pain is not taken seriously or that the nurse is reluctant to provide pain relief. The nurse would teach the client alternative comfort measures, such as relaxation techniques, distraction, or massage, as a supplement to the pain medication, not as a substitute.

Choice B reason: Telling the client that it is too soon for pain medication is not a good recommendation for the nurse to implement, as it may make the client feel dismissed, ignored, or judged. The nurse would follow the prescribed pain medication schedule, but also consider the client's individual needs and preferences, and adjust the dosage or frequency as needed, with the doctor's approval.

Choice C reason: Administering the pain medication as requested by the client is not a safe recommendation for the nurse to implement, as it may cause overdose, addiction, or adverse effects. The nurse would administer the pain medication as prescribed by the doctor, and monitor the client's response, side effects, and vital signs.

Choice D reason: Validating the pain with other assessment data is the best recommendation for the nurse to implement, as it shows respect, empathy, and professionalism. The nurse would acknowledge the client's pain, ask about the location, intensity, quality, and duration of the pain, and use a pain scale or a pain assessment tool to measure the pain. The nurse would also check for any physical or behavioral signs of pain, such as grimacing, guarding, or restlessness. The nurse would document the pain assessment and report any changes or concerns to the doctor.

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Correct Answer is ["A","B","D","E"]

Explanation

Choice A reason: Turning immobile clients every 2 hours off bony prominences can reduce the pressure and friction that can cause skin breakdown and ulcer formation.

Choice B reason: Using lift or draw sheets to move clients in bed can prevent dragging or pulling the skin, which can cause shear and damage the underlying tissue.

Choice C reason: Keeping the skin moist is not a correct way to prevent pressure ulcers. Moisture can weaken the skin and make it more prone to injury. The skin should be kept dry and clean, and moisturized if needed.

Choice D reason: Ensuring that your client maintains a healthy nutritional status can promote wound healing and prevent infection. Adequate protein, calories, vitamins, and minerals are essential for skin integrity and tissue repair.

Choice E reason: Applying pressure-relieving devices to vulnerable areas can distribute the pressure and protect the skin from damage. Examples of pressure-relieving devices are foam pads, air mattresses, or cushions.

A. Control fluid balance. B. Control blood pressure. C. Prevent deconditioning. D. Maintain client safety.

Correct Answer is A

Explanation

Choice A reason: Controlling fluid balance is the most important goal in the nursing plan of care to decrease the frequency of hospitalizations for acute exacerbations of HF in older adults, as fluid overload is the main cause of HF worsening and hospital admission. Fluid balance can be controlled by monitoring weight, intake and output, edema, and lung sounds, and by administering diuretics, restricting sodium and fluid intake, and elevating the legs.

Choice B reason: Controlling blood pressure is an important goal in the nursing plan of care to decrease the frequency of hospitalizations for acute exacerbations of HF in older adults, as hypertension is a risk factor and a complication of HF. However, it is not the most important goal, as blood pressure may not always reflect the fluid status or the severity of HF. Blood pressure can be controlled by administering antihypertensive medications, such as angiotensin-converting enzyme inhibitors, beta-blockers, or calcium channel blockers, and by encouraging lifestyle modifications, such as smoking cessation, weight management, and stress reduction.

Choice C reason: Preventing deconditioning is an important goal in the nursing plan of care to decrease the frequency of hospitalizations for acute exacerbations of HF in older adults, as deconditioning is a common problem in HF patients due to reduced physical activity, fatigue, and muscle wasting. However, it is not the most important goal, as deconditioning may not directly affect the fluid balance or the cardiac function. Deconditioning can be prevented by providing exercise training, such as aerobic, resistance, or interval training, and by promoting self-care and adherence to the treatment regimen.

Choice D reason: Maintaining client safety is an important goal in the nursing plan of care to decrease the frequency of hospitalizations for acute exacerbations of HF in older adults, as HF patients are at risk of falls, injuries, infections, or adverse drug reactions. However, it is not the most important goal, as client safety may not specifically address the fluid balance or the cardiac function. Client safety can be maintained by providing a safe environment, such as removing clutter, providing adequate lighting, and using assistive devices, and by preventing complications, such as monitoring for signs of infection, bleeding, or electrolyte imbalance, and by educating the client and the family about the medications, the signs and symptoms of HF worsening, and the emergency measures.

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An older adult admitted for back surgery asks for opioid pain medication. The nurse knows the client asks for pain medication 30 minutes before it is due. Which recommendation should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Pressure ulcers are defined as an injury to the skin and/or underlying tissue resulting from pressure or in combination with shear, usually over a bony prominence. As a nurse, what do you know you must do to prevent pressure ulcers? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

Which of the following is the most important goal in the nursing plan of care to decrease the frequency of hospitalizations for acute exacerbations of heart failure (HF) in older adults?

Correct Answer is A

Explanation

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