The nurse is evaluating the client’s response to pain management.
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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Advise the UAP to stop providing care so the nurse can assess the client's condition: The client shows signs of acute deterioration, which may indicate a life-threatening event. Immediate assessment takes priority over continuing routine tasks or delegating care.
B. Determine why the UAP did not notify the nurse of the change in the client's condition: Investigating the UAP’s actions is important for accountability and education but is secondary to addressing the client’s urgent medical needs.
C. Ask the UAP to position the client so the oral medications can be administered: Administering medications is not the priority when the client is unstable. Ensuring patient safety and assessing the acute condition comes first.
D. Explain to the UAP that changes in a client's condition should be reported immediately: Educating the UAP is necessary to prevent future incidents but does not address the immediate need to evaluate and stabilize the deteriorating client.
Correct Answer is D
Explanation
A. Explain to the client to inform others that they may have been potentially exposed in the last 14 days: While educating the client about notifying contacts is important, it does not prevent immediate transmission within the healthcare setting. It is a secondary measure.
B. Update the client and family regarding the COVID-19 vaccines that are available: Providing vaccine information is useful for long-term prevention but does not address the urgent need to reduce the risk of transmission from a potentially contagious client.
C. Notify the charge nurse the client will need assignment to the COVID-19 specified area of the facility: Assigning the client to a designated area is important for infection control, but the immediate priority is preventing exposure to others while awaiting placement.
D. Isolate the client from other clients, family, and healthcare workers not wearing proper PPE: Immediate isolation is the most critical action to prevent the spread of COVID-19. This protects other clients, visitors, and staff while testing and further management are arranged.
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