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Patient Data

Exhibits

Based on the trending heart rate and pain score, what should the nurse do? Select all that apply.

Assess for sources of pain other than the surgical site.

Change to a behavioral pain scale.

Give a dose of 2.5 mg of morphine.

Refer to social work for drug-seeking behavior.

Bring an opioid reversal agent to the bedside.

Lead the client in guided imagery.

Consult with the surgeon about the pain level.

Helping the client walk around the room.

Answer and Explanation

Correct Answer : A,C,G,H

Choice A reason:
The increase in heart rate from 78 to 118 beats per minute, along with the increase in pain rating from 3 to 8, suggests that the client may be experiencing pain from a source other than the surgical site. It is important to assess for other potential sources of pain to ensure comprehensive pain management.
Choice B reason:
Changing to a behavioral pain scale is not indicated in this scenario. The numerical pain scale is a standard and effective method for assessing pain levels, and there is no indication that the client has difficulty communicating her pain using this scale.
Choice C reason:
Given that the client's pain rating increased to 8, which is above the threshold of 4 on the pain scale, administering a dose of 2.5 mg of morphine as per the orders is appropriate to manage her pain.
Choice D reason:
Referring to social work for drug-seeking behavior is not supported by the information provided. The client's increased pain rating and heart rate suggest a legitimate need for pain management rather than drug-seeking behavior.
Choice E reason:
Bringing an opioid reversal agent to the bedside is not indicated unless there is a concern for opioid overdose, which is not suggested by the information provided.
Choice F reason:
While guided imagery can be a helpful adjunct for pain management, it is not the primary intervention needed at this time given the client's significant increase in pain and heart rate.
Choice G reason:
Consulting with the surgeon about the client's increased pain level is important to rule out any complications from the surgery and to discuss further pain management strategies.
Choice H reason:
Assisting the client to walk around the room may help in pain management and is part of the postoperative care plan to increase walking distance. However, it should be done cautiously considering the client's current pain level.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: Drinking 800 to 1,000 milliliters of fluid daily is below the recommended intake for most adults, which is generally around 2,000 milliliters per day to help prevent constipation.

Choice B reason: Oxycodone is an opioid that can actually lead to constipation, and its use should be carefully managed, not necessarily taken as scheduled for this purpose.

Choice C reason: Adding fat-containing foods is not a standard recommendation for preventing constipation; instead, a high-fiber diet is usually advised.

Choice D reason: Early and frequent ambulation is encouraged postoperatively to help stimulate bowel function and prevent constipation.

Correct Answer is ["2"]

Explanation

The healthcare provider has prescribed 4,800 mg of magnesium hydroxide. The bottle indicates that each 5 mL contains 400 mg of magnesium hydroxide. We also know that 1 ounce (oz) is equivalent to 30 mL.

Step 1: The amount of magnesium hydroxide the patient needs is 4,800 mg.

Step 2: The concentration of the magnesium hydroxide solution is 400 mg per 5 mL. Step 3: Substitute the values into the formula: 4,800 mg ÷ (400 mg/5 mL).

Step 4: Calculate the volume in mL: 4,800 ÷ (400/5) = 60 mL.

Now, we need to convert this volume from mL to ounces.

Step 5: We know that 1 oz = 30 mL.

Step 6: Substitute the values into the formula: 60 mL ÷ 30 mL/oz.

Step 7: Calculate the volume in oz: 60 ÷ 30 = 2 oz.

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Patient Data Exhibits Based on the trending heart rate and pain score, what should the nurse do? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing postoperative teaching to a client on ways to prevent constipation. Which information should the nurse include?

Correct Answer is D

Explanation

Correct Answer is ["2"]

Explanation

When interviewing a client about sexuality/reproductive function, which is the best approach for the nurse to use?

During the admission assessment to the hospital, an adult client reports being allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

A nurse finds a confused client wandering in the hallway during the night. What actions should the nurse implement? Select all that apply.

Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning?

A patient with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the patient's fluid balance?

Patient Data

Exhibits

Based on the trending heart rate and pain score, what should the nurse do? Select all that apply.