The health care provider orders a patient-controlled analgesia (PCA) machine to provide pain relief for a patient with acute surgical pain who has never received opioids before. Which nursing actions regarding opioid administration are appropriate at this time? (Select all that apply.)

Emphasize that their spouse may push the pain button when they are uncomfortable

Provide instructions on decreasing opioid doses by the second postoperative day.

Teach the patient about how analgesics improve postoperative activity levels.

Monitor for therapeutic and adverse effects of opioid administration.

Assess for signs that the patient is becoming addicted to the opioid.

Answer and Explanation

Correct Answer : C,D

C. Education about the benefits of pain management, including how analgesics can improve postoperative activity levels by reducing pain and discomfort, helps to promote the patient's understanding and engagement in their own care.

D. Nurses should closely monitor the patient for both therapeutic effects and adverse effects of opioid administration when using PCA or any other opioid analgesic. Regular assessment allows for prompt identification and management of any complications or side effects.

A. Patient-controlled analgesia (PCA) is designed for the patient to self-administer pain medication according to their own needs and pain levels.

B. Opioid dosing should be individualized based on the patient's pain level and response to the medication. Some patients may require ongoing opioid analgesia for more than two days postoperatively, while others may be able to transition to alternative pain management strategies sooner.

E. Concerns about opioid addiction should not be assumed in all patients, especially those who have never received opioids before. Instead, the focus should be on assessing the patient's pain levels, response to pain medication, and any adverse effects.

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Correct Answer is B

Explanation

B. Methamphetamine use can cause significant cardiovascular effects, including tachycardia, hypertension, and arrhythmias. Given the patient's presentation with an irregular heart rate and tachycardia, continuous cardiac monitoring through an ECG is essential to assess for any life-threatening arrhythmias or other cardiac complications.

A. Reorientation is important for patients who are disoriented, but in the case of a patient who has admitted to using methamphetamine and is exhibiting signs of agitation and tachycardia, the priority is to ensure the patient's safety and stabilize their condition.

C. While providing a calm environment is beneficial for patients who are agitated, it is not the most important action in this scenario.

D. Obtaining a comprehensive health history, including prior drug use, is important for understanding the patient's background and potential risk factors. However, in this acute situation where the patient is disoriented, agitated, and exhibiting signs of cardiovascular distress, the priority is to address the immediate medical needs and stabilize the patient's condition.

A. Tympanic temperature 99.2° F (37.3° C) B. Fine crackles audible at both lung bases C. 200 mL sanguineous fluid in the wound drain D. Redness and swelling along the suture line

Correct Answer is C

Explanation

C. Excessive sanguineous fluid in the drain could indicate active bleeding or a hematoma formation, which are significant concerns after surgery. It should be reported to allow for appropriate intervention to prevent shock

A. A slight elevation in temperature can be expected in the immediate postoperative period due to the body's response to surgery (surgical stress response).

B. Fine crackles indicate the presence of fluid in the lungs, which could suggest complications such as pulmonary edema or atelectasis. While this finding warrants monitoring and intervention, it may not be the most critical issue to report to the surgeon in this context.

D. Redness and swelling along the suture line can indicate inflammation or infection at the surgical site. This is a normal response of the tissues to trauma such as surgery.

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The health care provider orders a patient-controlled analgesia (PCA) machine to provide pain relief for a patient with acute surgical pain who has never received opioids before. Which nursing actions regarding opioid administration are appropriate at this time? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A disoriented and agitated patient comes to the emergency department and admits using methamphetamine. Vital signs are blood pressure 164/94 mm Hg. heart rate 136 beats/min and irregular, and respirations 32 breaths/min. Which action by the nurse is most important?

Correct Answer is B

Explanation

The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon?

Correct Answer is C

Explanation

A nurse is caring for a client who has a prescription for balanced skeletal traction with a Thomas splint for the treatment of a fractured femur. Which of the following interventions should the nurse implement to prevent pressure points from developing around the edges of the splint?

A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status?

A nurse is assessing a client following the application of a leg cast for the treatment of a fracture. If the cast is too tight, which of the following findings should the nurse expect to observe first?

A nurse is providing care for four clients on a medical-surgical unit, Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)

A patient is admitted to the postanesthesia care unit (PACU) with a blood pressure (BP) 122/72 mm Hg. Thirty minutes after admission, the BP is 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate?

A nurse is teaching a client about risk factors for osteoarthritis. Which of the following factors should the nurse include in the teaching? (Select all that apply.)

An unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago has an oxygen saturation of 89%. Which action should the nurse take first?