Patient Data

Exhibits

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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A Reason: This is incorrect because instilling normal saline solution into the nasogastric tube can cause fluid overload, electrolyte imbalance, or aspiration. Clamping the tube for one hour can also increase the risk of aspiration and gastric distension.

Choice B Reason: This is incorrect because turning the suction off can cause gastric distension and discomfort. Rinsing the mouth with cool water can also increase the risk of aspiration if the client swallows some of the water.

Choice C Reason: This is correct because oral sponge toothettes are soft and gentle on the oral mucosa and can help moisten and cleanse the mouth without causing irritation or aspiration.

Choice D Reason: This is incorrect because teaching the client that the oral mucosa must remain dry is false and can lead to further dryness, cracking, bleeding, and infection. The oral mucosa should be kept moist and clean to prevent these complications.

A. Regular exercise. B. Stress reduction. C. Smoking cessation. D. Low-fat diet.

Correct Answer is C

Explanation

Choice A: Regular exercise is a good lifestyle modification, but it is not as important as smoking cessation. Exercise can help lower blood pressure, cholesterol, and weight, but it cannot reverse the damage caused by smoking.

Choice B: Stress reduction is a good lifestyle modification, but it is not as important as smoking cessation. Stress can trigger or worsen cardiac problems, but it cannot cause them as directly as smoking.

Choice C: Smoking cessation is the most important lifestyle modification because smoking is a major risk factor for cardiac disease. Smoking damages the blood vessels, increases blood pressure, reduces oxygen supply, and promotes clot formation.

Choice D: Low-fat diet is a good lifestyle modification, but it is not as important as smoking cessation. A low-fat diet can help lower cholesterol and prevent plaque buildup, but it cannot undo the effects of smoking.

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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

A male client with a nasogastric tube connected to low intermittent suction tells the nurse that his mouth is very dry. Which action should the nurse implement?

Correct Answer is C

Explanation

A client with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage?

Correct Answer is C

Explanation

The nurse administers morphine to a client for chest pain who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?

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

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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.