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The nurse is evaluating the client’s response to pain management.

Exhibits

Click to highlight the findings that indicate the client is experiencing the therapeutic effects of the medication.

Pain level presently 3 on a 0 to 10 scale. The client reports feeling “sleepy.” Client is able to take deep breaths, achieving 1,000 mL on incentive spirometer. New mild cough noted. Repositions in bed with minimal assistance. Attempted to get up to the chair, but experienced dizziness with standing.

Pain level presently 3 on a 0 to 10 scale

The client reports feeling "sleepy

Client is able to take deep breaths, achieving 1,000 mL on incentive spirometer

New mild cough noted.

Repositions in bed with minimal assistance.

Attempted to get up to the chair, but experienced dizziness with standing.

Answer and Explanation

The Correct Answer is ["A","C","E"]

Rationale for correct choices:

• Pain level presently 3 on a 0 to 10 scale: A reduction in pain from 8/10 to 3/10 indicates that the morphine is effectively alleviating the client’s pain. Effective analgesia allows for improved comfort, participation in breathing exercises, and reduced stress response.

• Client is able to take deep breaths, achieving 1,000 mL on incentive spirometer: Increased inspiratory volume demonstrates improved lung expansion, indicating that pain control is facilitating better respiratory effort. This is especially important to prevent atelectasis and maintain adequate oxygenation after rib fractures.

• Repositions in bed with minimal assistance: Ability to move with less assistance reflects improved comfort and mobility due to effective pain management. This shows the therapeutic effect of analgesia in enabling functional activity without excessive pain.

Rationale for incorrect choices:

• Client reports feeling "sleepy": Sleepiness is a common side effect of morphine, reflecting central nervous system depression rather than a therapeutic effect of pain relief. While mild sedation can accompany effective analgesia, it does not directly indicate improvement in the underlying condition.

• New mild cough noted: The appearance of a new cough is not a direct indicator of therapeutic pain relief. It may reflect airway irritation, increased secretions, or a response to deeper breathing, but it is not a measure of analgesic effectiveness.

• Attempted to get up to the chair, but experienced dizziness with standing: Dizziness indicates a side effect of the opioid (orthostatic hypotension or sedation), not a therapeutic response. This finding requires monitoring and safety interventions.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Wake all the clients and instruct them to go to dining area for medication administration: Waking all clients at once without adequate staffing may create safety risks and chaos, especially on a mental health unit where supervision is essential.

B. Allow the clients to sleep until a third staff person can assist with unit activities: Delaying medication administration could compromise timely treatment and therapeutic outcomes, making this an unsafe approach.

C. Explain to the clients that it will be necessary to cooperate until another RN arrives: While client communication is important, it does not address the immediate need for safe medication administration and supervision.

D. Ask the PN to administer medications as clients are awakened so both nurses are available: Delegating medication administration to the PN while clients are awakened in a staggered, controlled manner ensures timely delivery of medications, maintains client safety, and allows the nurse to supervise and manage the unit effectively during a staffing shortage.

A. Nausea and vomiting B. Fatigue and weakness C. Bradycardia D. Visual disturbances (e.g., yellow-green halos) E. Hypertension

Correct Answer is ["A","B","C","D"]

Explanation

A. Nausea and vomiting: Gastrointestinal symptoms such as nausea, vomiting, and anorexia are common early signs of digoxin toxicity and should be closely monitored.

B. Fatigue and weakness: Generalized fatigue and muscle weakness can result from digoxin toxicity due to its effects on cardiac output and electrolyte imbalances, indicating early toxicity.

C. Bradycardia: Digoxin increases vagal tone, which can lead to bradycardia. A heart rate below 60 bpm is a key warning sign of digoxin toxicity.

D. Visual disturbances (e.g., yellow-green halos): Visual changes, including blurred vision, yellow-green halos, or altered color perception, are classic manifestations of digoxin toxicity and require prompt recognition.

E. Hypertension: Hypertension is not typically associated with digoxin toxicity; digoxin more commonly causes bradyarrhythmias and hypotension rather than elevated blood pressure.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Patient Data Exhibits Which of the following findings should the nurse recognize as manifestations of digoxin toxicity? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

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Patient Data Exhibits Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. Based on the client's condition, the priority need will be to address dropdown. In addition, he will need interventions to prevent dropdown_.