Patient Data

Exhibits

The nurse is providing education about opioid pain medication.

For each education point, click to indicate whether it is appropriate or not appropriate to provide to the client. Each row must have one response option selected.

Increase your water and fiber intake while taking opioids.

Expect the morphine to take 1 to 2 hours for full effect.

Request pain medication only if pain is severe.

Use incentive spirometer when the pain medication takes effect.

Ask for assistance when getting out of bed after taking morphine.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}

Rationale for correct choices:

• Increase your water and fiber intake while taking opioids: Opioids frequently cause constipation by slowing gastrointestinal motility. Encouraging adequate hydration and fiber intake helps prevent constipation and maintain bowel regularity, which is an essential part of opioid education.

• Expect the morphine to take 1 to 2 hours for full effect: IV morphine typically takes effect within 5 to 10 minutes, with peak analgesic effect in about 20 minutes. Telling the client it takes 1 to 2 hours may cause confusion and unnecessary delay in using other comfort measures.

• Request pain medication only if pain is severe: Waiting until pain is severe can result in poor pain control and decreased participation in respiratory exercises. Encouraging timely administration before pain becomes severe promotes better analgesia and facilitates lung expansion.

• Use incentive spirometer when the pain medication takes effect: Pain can limit the client’s ability to perform deep breathing exercises. Using the incentive spirometer when analgesia is effective promotes lung expansion, reduces atelectasis risk, and improves oxygenation in clients with rib fractures.

• Ask for assistance when getting out of bed after taking morphine: Morphine can cause dizziness, orthostatic hypotension, or sedation, increasing fall risk. Asking for assistance ensures client safety during ambulation or position changes, especially in older adults with recent trauma.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

Rationale:

• Instruct incentive spirometry use every hour: Indicated to promote lung expansion and prevent complications such as pneumonia or atelectasis. Even though the infection is in the leg, maintaining adequate oxygenation and pulmonary function is critical in older adults with multiple comorbidities.

• Use petroleum-based lotion on skin: Contraindicated because petroleum-based products can trap moisture and bacteria, increasing the risk of worsening cellulitis or skin breakdown. Non-occlusive, water-based moisturizers are safer for diabetic or infected skin.

• Administer antibiotics: Indicated as the client has a bacterial infection (cellulitis) with erythema, warmth, swelling, and elevated WBC count. IV cefazolin is prescribed to treat the infection promptly and prevent progression to sepsis.

• Suggest that client ambulate often: Contraindicated because the affected leg is inflamed, painful, and at risk for injury or worsening edema. Early ambulation may exacerbate discomfort and impair healing; activity should be gradual and guided by pain tolerance and clinical stability.

• Encourage consumption of protein and vitamin C: Indicated to support wound healing and immune function. Adequate protein and vitamin C intake are essential for tissue repair and recovery from infection, particularly in older adults with chronic comorbidities.

• Apply thromboembolism deterrent stockings (TED): Indicated to prevent venous thromboembolism, especially since the client has limited mobility due to pain and swelling, advanced age, and comorbid conditions like heart failure and diabetes.

A. Note and report the client's food and liquid intake during meals and snacks. B. Assess the client for weakness and fatigue. C. Report any client mention of pain or discomfort. D. Weigh the client and report any weight gain. E. Evaluate the client for sleep disturbances.

Correct Answer is ["A","C","D"]

Explanation

A. Note and report the client's food and liquid intake during meals and snacks: UAPs can monitor and document intake and output, then report to the nurse for evaluation. This is within their role.

B. Assess the client for weakness and fatigue: Assessment requires nursing judgment and interpretation of findings, which cannot be delegated to UAPs.

C. Report any client mention of pain or discomfort: UAPs may report observations or client statements to the nurse. The nurse is responsible for further assessment and management.

D. Weigh the client and report any weight gain: Daily weights and reporting results are appropriate UAP tasks, as they are routine and measurable without requiring clinical judgment.

E. Evaluate the client for sleep disturbances: Evaluation involves analysis and clinical decision-making, which must be performed by the nurse, not the UAP.

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Patient Data Exhibits The nurse is providing education about opioid pain medication. For each education point, click to indicate whether it is appropriate or not appropriate to provide to the client. Each row must have one response option selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

The nurse is managing the care of a client with Cushing's syndrome. Which intervention(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

A client receives a prescription for itraconazole. Which statement made by the client requires additional instruction by the nurse?

Patient Data Exhibits The nurse is providing education about opioid pain medication. For each education point, click to indicate whether it is appropriate or not appropriate to provide to the client. Each row must have one response option selected.

Patient Data Exhibits The nurse needs to determine the priority assessment before administering morphine. Select from Word Choices to complete the sentence. Before administering morphine, the most important assessment to perform is to check the client's ______________

The nurse is administering multiple prescribed vaccines to a toddler. Which strategy should the nurse prioritize to reduce the duration of pain?

After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?

After receiving report on an inpatient acute care unit, which client should the nurse assess first?

The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which health care measure is most important for the nurse to recommend to these clients?

The parents of an infant with chronic health conditions have cognitive challenges and diverse educational backgrounds. Which intervention(s) should the nurse implement to support them in safely administering medications to their child? Select all that apply.

Patient Data

Exhibits

The nurse is providing education about opioid pain medication.

For each education point, click to indicate whether it is appropriate or not appropriate to provide to the client. Each row must have one response option selected.