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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["C","E","G"]

Explanation

A. IV site without redness or swelling: The IV site appears normal with no signs of infiltration or infection, so no immediate follow-up is required. This finding indicates proper IV insertion and maintenance.

B. Temperature: 98.8° F (37.1° C): This is within normal limits and does not indicate fever or infection, so it does not require immediate follow-up.

C. Respirations: 28 breaths/minute: This is above the normal adult range (12–20 breaths/minute) and may indicate respiratory distress due to pain, shallow breathing, or possible pulmonary complications such as atelectasis or pneumonia, requiring close monitoring and follow-up.

D. Heart rate: 92 beats/minute: Slightly elevated but within mild tachycardia range, which could be related to pain or anxiety. It should be monitored but does not require urgent follow-up.

E. Taking shallow breaths: Shallow breathing is concerning in a client with rib fractures, as it increases the risk for hypoventilation, atelectasis, and pneumonia. This requires immediate intervention, such as pain management and respiratory support.

F. Alert and oriented to person, place, time, and situation: Cognitive status is normal, so no follow-up is needed.

G. Pain 8 on a 0 to 10 scale: Severe pain limits deep breathing and mobility, increasing the risk of complications. Pain management should be addressed promptly to improve comfort and respiratory function.

H. Blood pressure: 138/82 mm Hg: Slightly elevated, likely related to pain or stress. Monitor trends, but it does not require immediate follow-up at this time.

A. Offer to discuss the client's health status with each of the adult children. B. Reassure the spouse that the healthcare provider (HCP) will notify when to call the children. C. Gather information regarding how long it will take for the children to arrive. D. Explain that the client will start to lose consciousness and the body systems will slow down.

Correct Answer is D

Explanation

A. Offer to discuss the client's health status with each of the adult children: While involving family in discussions is important, the immediate question from the spouse is about recognizing signs of imminent death. Directly explaining the physiological changes is more appropriate at this moment.

B. Reassure the spouse that the healthcare provider (HCP) will notify when to call the children: Waiting for the HCP to give a signal does not provide the spouse with the knowledge they are seeking. It may delay preparation and increase anxiety during the final hours.

C. Gather information regarding how long it will take for the children to arrive: While logistical planning is helpful, it does not address the spouse’s question about recognizing imminent death and understanding what to expect.

D. Explain that the client will start to lose consciousness and the body systems will slow down: Providing clear, compassionate information about the expected signs of dying helps the spouse recognize that death is near, allows family members to prepare emotionally, and facilitates meaningful final interactions with the client.

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

Correct Answer is ["C","E","G"]

Explanation

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?

Correct Answer is D

Explanation

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The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

Patient Data Exhibits Which laboratory test(s) would be helpful in determining the plan of care (POC) for this client? Select all that apply.

A male client in the final stages of terminal cancer tells his nurse that he wishes he could just be allowed to die. The client verbalizes that he is tired of fighting this illness and is only continuing treatments because his family wants him to live. Which action should the nurse take?

A client in labor begins bleeding profusely from the vagina. Which findings should the nurse report to the healthcare provider?

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.