Patient Data

Exhibits

The nurse addresses the client's pain and plans interventions to reduce further complications.

Choose the most likely options for the information missing from the statements by selecting from the lists of options provided.

The nurse monitors the client's
dropdown
after administering the morphine. The nurse should include
dropdown
to reduce complications of the client's injury.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Rationale for correct choices:

• Respirations: Morphine is an opioid analgesic that can depress the respiratory center in the brainstem, leading to slowed breathing and hypoventilation. Monitoring respirations after administration is critical to detect early signs of opioid-induced respiratory depression.

• Ice application to the shoulder: Applying ice reduces swelling, pain, and inflammation by causing vasoconstriction and limiting fluid accumulation at the injury site. For an acute humeral fracture with significant swelling and bruising, cold therapy is the appropriate intervention.

Rationale for incorrect choices:

• Nausea: While morphine can cause nausea and vomiting as side effects, they are not the most life-threatening concerns compared to respiratory depression. Monitoring nausea is appropriate but not the priority when evaluating opioid safety.

• Blood pressure: Morphine can cause hypotension, but this effect is less common and typically secondary to respiratory depression and vasodilation. Continuous monitoring of blood pressure is helpful, but respiratory monitoring takes priority in detecting opioid complications.

• Early active range of motion: Active movement of the injured arm is not recommended immediately after a displaced humeral fracture, as it can worsen displacement and interfere with healing. Immobilization and stabilization are required before introducing range-of-motion exercises.

• Heat application to the shoulder: Heat increases blood flow to tissues, which can worsen swelling and bleeding in the acute phase of injury. Applying heat too soon after a fracture increases the risk of complications rather than reducing them.

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Correct Answer is B

Explanation

A. Verbal reassurance: While helpful for reducing anxiety, verbal reassurance alone does not significantly shorten the duration of pain associated with multiple injections.

B. Simultaneous injections: Administering multiple vaccines at the same time in different sites reduces the overall number of needle sticks and the total duration of pain the toddler experiences, making this the most effective strategy.

C. Supine positioning: Proper positioning can improve safety and comfort during injections but does not directly decrease the duration of pain from the procedure.

D. Physical soothing: Holding or comforting the toddler helps reduce distress and anxiety, but it does not shorten the actual time the pain stimulus occurs.

A. Irrigate conjunctiva with ophthalmic saline prior to instilling antibiotic ointment. B. Limit exposure to sunlight during the first 2 weeks when the cornea is healing. C. Avoid straining at stool, bending, or lifting heavy objects. D. Do not read without direct lighting for 6 weeks.

Correct Answer is C

Explanation

A. Irrigate conjunctiva with ophthalmic saline prior to instilling antibiotic ointment: Routine irrigation is not typically necessary unless instructed for debris removal. Over-manipulation may increase the risk of infection or injury to the healing eye.

B. Limit exposure to sunlight during the first 2 weeks when the cornea is healing: While sunglasses can protect the eyes from UV light, strict limitation of sunlight is not usually required for 2 weeks. Standard protective measures and avoiding direct glare are sufficient.

C. Avoid straining at stool, bending, or lifting heavy objects: These activities increase intraocular pressure, which can compromise the surgical site and healing process after cataract extraction. Avoiding them is critical to prevent complications such as wound dehiscence or hemorrhage.

D. Do not read without direct lighting for 6 weeks: Reading is generally safe after cataract surgery as long as the client uses appropriate lighting. There is no standard requirement to avoid reading for 6 weeks.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is B

Explanation

The nurse is preparing an older adult client for discharge following cataract extraction. Which instruction should be included in the discharge teaching?

Correct Answer is C

Explanation

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

The nurse is caring for a client whose BMI is 35 kg/m². Which condition(s) is/are the client at greatest risk of developing? Select all that apply.

A client who had bariatric surgery 2 months ago is admitted because of vomiting and inability to tolerate food and liquids. The client is pain free. Which intervention should the nurse include in the client's plan of care?

A client is receiving a secondary infusion of erythromycin 1 grams in 100 mL dextrose 5% in water (D5W) to be infused in 30 minutes. How many mL/hour should the nurse program the infusion pump? (Enter numerical value only.)

Patient Data <pre> Exhibits <p>For each assessment finding, click to indicate whether the findings from the client's assessment are generally associated with rotator cuff injury and/or humeral fracture. Each column must have at least one response selected.</p>

A client on the mental health unit has been scowling and rapidly pacing up and down the hall for several minutes. Which behaviors are most important for the nurse to monitor?