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.

Nursing Test Bank

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Correct Answer is C

Explanation

A. Risk for fluid and electrolyte imbalance: While important, this risk is secondary to the immediate physiological consequences of insufficient nutrition. Electrolyte imbalances often develop as a result of malnutrition and require close monitoring.

B. Disturbed body image related to loss of control: Body image disturbance is central to anorexia nervosa, but it does not pose an immediate threat to life. Psychological interventions are essential but follow stabilization of physical health.

C. Imbalanced nutrition less than body requirements: Inadequate nutrition directly threatens physiological stability, affecting cardiovascular, gastrointestinal, and endocrine function. Restoring adequate nutrition is the highest priority to prevent life-threatening complications such as organ failure or severe electrolyte disturbances.

D. Impaired coping related to excessive physical activity: Excessive exercise may worsen malnutrition and stress, but it is secondary to the urgent need to correct nutritional deficits and stabilize the client’s physical condition.

A. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds. B. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity. C. The client with an obstruction of the large intestine who is experiencing abdominal distention. D. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid.

Correct Answer is B

Explanation

A. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds: Paralytic ileus is common postoperatively and, while concerning, is usually not immediately life-threatening.

B. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity: Abdominal rigidity suggests possible bowel ischemia or perforation, which are surgical emergencies. This client is at highest risk for rapid deterioration and requires immediate assessment and intervention.

C. The client with an obstruction of the large intestine who is experiencing abdominal distention: While abdominal distention indicates obstruction, it is not immediately life-threatening unless accompanied by signs of ischemia or perforation.

D. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid: NG drainage is expected with small bowel obstruction and indicates decompression is occurring. This is less urgent than a client showing signs of peritonitis.

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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

The nurse is caring for a client with anorexia nervosa who states, "I feel powerless when I gain weight." Which problem should the nurse identify as a priority?

Correct Answer is C

Explanation

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

Correct Answer is B

Explanation

Patient Data Exhibits The nurse is reviewing the client's initial assessment findings. Which assessment findings require follow-up? Select all that apply.

An adult client was diagnosed with stage IV lung cancer three weeks ago. The client's spouse approaches the nurse and asks, "How will I know that my husband's death is imminent? Our two adult children want to be here when their father dies." Which is the best response by the nurse?

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

A client with a history of alcohol addiction says, "My body feels fine when I abstain from alcohol consumption, but I miss my late night glasses of wine." Which concept should the nurse discuss with the client?

A client who is receiving zidovudine reports the appearance of pinpoint, red, round spots on the skin. Which result should the nurse report to the healthcare provider (HCР)?

A 3-year-old client was successfully toilet trained prior to admission to the hospital for injuries sustained from a fall. The client's parents are very concerned that the child has regressed in toileting behaviors. Which information should the nurse provide to the parents?

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.