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 A

Explanation

A. This technique helps to prevent pressure ulcers and assists in maintaining proper spinal alignment, which is essential after such a surgery.

B. Clear drainage on the spinal dressing is not typically expected and could indicate an infection or other complication.

C. Assisting the client to sit upright in a chair for extended periods is not standard practices immediately following spinal fusion, as these actions may put undue stress on the spine during the critical initial healing phase.

D. Elevating the client's legs while sitting are not standard practices immediately following spinal fusion, as these actions may put undue stress on the spine during the critical initial healing phase

A. Apply lotion to the skin under the edges of the splint. B. Reposition the client to keep him from staying in the same position in bed. C. Remove the weights for a few minutes each hour. D. Apply a foot plate to the bed.

Correct Answer is B

Explanation

B. Repositioning the client regularly is an important intervention to prevent pressure ulcers and pressure points, especially when the client is immobilized in traction. Repositioning helps distribute pressure evenly on different areas of the body, reducing the risk of tissue ischemia and pressure-related injuries around the edges of the splint.

A. Lotions or moisturizers can increase the risk of skin breakdown and infection, especially when applied under medical devices such as splints or casts.

C. Removing the weights for a few minutes each hour is not necessary to prevent pressure points around the edges of the splint. Balanced skeletal traction is typically applied to maintain continuous traction force on the fractured femur for therapeutic purposes.

D. Applying a foot plate to the bed is not directly related to preventing pressure points around the edges of the splint. Foot plates are typically used to prevent foot drop and maintain proper alignment of the foot and ankle joints.

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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 nurse is caring for a client who is 1-day postoperative following spinal fusion. Which of the following actions should the nurse take?

Correct Answer is A

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?

Correct Answer is B

Explanation

A nurse is caring for a client who has a fractured tibia as a result of a fall. The client x-ray shows that the bone is splintered into several pieces around the shaft. The nurse should identify that the client has which of the following types of fractures?

A nurse is teaching a newly licensed nurse about the difference between a plaster cast and a synthetic cast. Which of the following information should the nurse include in the teaching?

A nurse is teaching a client who has a new prescription for cyclosporine oral solution to treat rheumatoid arthritis. Which of the following information should the nurse include in the teaching?

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 post-operative patient is scheduled for ambulation. Which of the following patients should be prioritized for ambulation?

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?

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?

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.)