Patient Data
Based on the trending heart rate and pain score, what should the nurse do? Select all that apply.
Lead the client in guided imagery
Give a dose of 2.5 mg of Morphine
Assist the client to walk around the room
Assess for sources of pain other than the surgical site
Consult with the surgeon about the pain level
Correct Answer : A,D,E
Choice A: Lead the client in guided imagery
This is a correct choice because guided imagery is a non-pharmacological intervention that can help reduce pain and anxiety by creating a relaxing mental image for the client. Guided imagery can also lower the heart rate and blood pressure by activating the parasympathetic nervous system.
Choice B: Give a dose of 2.5 mg of Morphine
This is an incorrect choice because morphine is an opioid analgesic that can cause respiratory depression, hypotension, and bradycardia. The client's heart rate is already elevated, which could indicate inadequate pain relief or anxiety. Giving more morphine could worsen the client's condition and mask the underlying cause of the pain.
Choice C: Assist the client to walk around the room
This is an incorrect choice because walking around the room could increase the client's pain and heart rate by stimulating the sympathetic nervous system. The client has already done ambulation exercises with physical therapy at 1200, so there is no need to repeat them at 1400. The client should be allowed to rest in bed and conserve energy.
Choice D: Assess for sources of pain other than the surgical site
This is a correct choice because the nurse should always assess the client holistically and rule out any other potential causes of pain, such as infection, inflammation, or ischemia. The nurse should also check the surgical site for any signs of bleeding, hematoma, or infection. The nurse should use a comprehensive pain assessment tool that includes the location, intensity, quality, duration, frequency, and aggravating and relieving factors of the pain.
Choice E: Consult with the surgeon about the pain level
This is a correct choice because the nurse should collaborate with the surgeon and other members of the health care team to provide optimal pain management for the client. The nurse should report the client's pain score, vital signs, medication administration, and response to interventions. The surgeon may order additional tests or medications to address the cause of the pain and improve the client's comfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because a one ounce medicine cup is not precise enough to measure a 5 mL dose of viscous liquid solution. A one ounce medicine cup can hold about 30 mL of liquid, which is too large for a small dose.
Choice B Reason: This is incorrect because a 3 mL syringe and a sterile needle is not appropriate for oral administration of medication. A needle may cause injury to the oral mucosa or the esophagus.
Choice C Reason: This is correct because a 3 mL syringe can measure a 5 mL dose of viscous liquid solution accurately and safely. A syringe can draw up the solution easily and deliver it to the mouth without spilling or dripping.
Choice D Reason: This is incorrect because a tuberculin syringe is too small to measure a 5 mL dose of viscous liquid solution. A tuberculin syringe can hold only 1 mL of liquid, which is not enough for the required dose.
Correct Answer is ["B"]
Explanation
Choice A Reason: This is incorrect because nociceptive pain is caused by stimulation of nociceptors, which are sensory receptors that respond to tissue damage or inflammation. Nociceptive pain is usually localized and throbbing or aching.
Choice B Reason: This is correct because neuropathic pain is caused by damage or dysfunction of the nervous system. Neuropathic pain is usually diffuse and burning or shooting.
Choice C Reason: This is incorrect because acute pain is defined by its duration rather than its cause or quality. Acute pain lasts less than six months and usually has an identifiable cause and predictable course.
Choice D Reason: This is incorrect because visceral pain is caused by stimulation of nociceptors in the internal organs. Visceral pain is usually deep and cramping or squeezing.
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