You are the nurse caring for an elderly post-operative patient who is 12 hours post-op and is on an around-the-clock regimen with opioid pain medications scheduled every 4 hours for pain prophylaxis and management. The next dose of scheduled pain medication is due soon. When planning care for this patient, you recognize that based on their current condition and vital signs they are at the most risk for which of the following (select all that apply)?

Exhibits

The nurse questions giving the next dose of opioid medication right now due to which of the following potential complications? (Select All that Apply.)

Respiratory depression

Tachycardia

Urinary frequency

Constipation

Hypotension

Answer and Explanation

Correct Answer : A,D,E

A. Respiratory depression is a common and serious side effect of opioid medications. The patient's respiratory rate is 11 breaths per minute, which is on the low end of normal and could be further depressed by additional opioid administration, increasing the risk of respiratory compromise.
B. Tachycardia is not a typical side effect of opioids. The patient’s heart rate is 72 beats per minute, which is within normal limits, and there is no indication of tachycardia.
C. Urinary frequency is unlikely to be caused by opioids. In fact, opioids can lead to urinary retention, not frequency, and the patient's urinary output is already low (480 mL in 12 hours), suggesting potential urinary retention.
D. Constipation is a common side effect of opioid use. The patient has not had a bowel movement in three days, and absent bowel sounds suggest the possibility of opioid-induced constipation.
E. Hypotension is a known side effect of opioids. The patient’s blood pressure is 90/54, which is on the low side, indicating that further opioid administration could exacerbate hypotension.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Removing and applying the fixator for showers is not appropriate. The external fixator should not be removed by the nurse without proper medical guidance. Showers should be managed in a way that prevents the fixator from becoming wet or contaminated.
B. Documenting pin site assessment and care is essential for clients with external fixation. The nurse should regularly assess pin sites for signs of infection (e.g., redness, swelling, drainage) and ensure proper care is provided to prevent complications.
C. Encouraging the patient to lie prone several times per day may not be necessary or appropriate unless specifically ordered by the provider. The patient’s positioning should be based on comfort and the provider’s instructions to avoid strain on the injured limb.
D. Turning the patient every 3 hours is a general nursing practice for preventing pressure ulcers, but it is not specific to the care of a client with external fixation. The focus should be on protecting the fixator and ensuring the limb is properly supported.

A. The pain comes from severed blood vessels in the residual stump. B. It is psychosomatic pain that the patient is just imagining. C. It is often treated with adjunct medications such as antiepileptics and antidepressants. D. It is somatic pain that always responds well to opioid medications.

Correct Answer is C

Explanation

A. The pain does not come from severed blood vessels in the residual stump. Phantom limb pain is not caused by the stump itself but rather by the brain’s perception of the missing limb.
B. Phantom limb pain is not psychosomatic. It is a real phenomenon where the brain continues to receive signals from nerves that were previously connected to the amputated limb.
C. Phantom limb pain is often treated with adjunct medications such as antiepileptics (e.g., gabapentin) and antidepressants (e.g., amitriptyline), which help modify the way the brain processes pain signals.
D. While opioid medications can be used for pain management, phantom limb pain often does not respond well to opioids. It typically requires a combination of other treatments, such as those mentioned in C.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with external fixation of the tibia. Which of the following would the nurse include in the plan of care?

Correct Answer is B

Explanation

A client who is recovering from a lower extremity amputation complains of tingling and "shooting" pain in the amputated extremity. The nurse knows that which of the following is true about this type of pain?

Correct Answer is C

Explanation

A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?

The nurse is caring for a client who was admitted for an acute exacerbation of Crohn's Disease with severe diarrhea for the last two days. The nurse knows that which of the following is the priority risk for this client?

A nurse is preparing to administer an infusion of intravenous fluids to a client who is at risk for fluid volume overload. Which of the following manifestations would indicate hypervolemia? (Select all that apply)

Which assessment finding is most indicative of hypernatremia?

A patient presents with a heart rate of 130 beats/minute and a blood pressure of 82/66 after exerting themselves in the sun. Which of the following interventions would be most appropriate?

The nurse is caring for a pediatric client who experienced a "greenstick" fracture. The client's mother asks the nurse what it means to have this type of fracture. Which of the following statements should the nurse make?

Which of the following actions is inappropriate when implementing precautions in a client with hyponatremia?