Nokea
To assess a client's dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes but does not feel a pulsation. Which action should the nurse take next?
- A. Reduce the amount of pressure being applied on the top of the foot.
- B. Document in the nurse's notes that the dorsalis pedis pulse is not palpable.
- C. Obtain a Doppler stethoscope to auscultate the pulse at the same site.
- D. Palpate the site on the inner side of the ankle below the medial malleolus.
Correct Answer: C
Rationale: Doppler detects weak pulses.
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The nurse is planning assignments for the staff on a medical-surgical unit. Which task should the nurse assign to the practical nurse (PN)?
- A. Complete an admission assessment.
- B. Access a central venous line.
- C. Reinforce discharge teaching.
- D. Initiate blood product infusions.
Correct Answer: C
Rationale: PNs can reinforce teaching within scope.
Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning?
- A. Using two or three people increases client safety.
- B. The technique is intended to maintain straight spinal alignment.
- C. Turning instead of pulling reduces the likelihood of skin damage.
- D. Working together can decrease the risk of back injury to the nurses.
Correct Answer: B
Rationale: Log rolling prevents spinal injury by maintaining alignment.
The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which action is most useful for the nurse to include during the teaching session?
- A. Offer positive reinforcement.
- B. Provide physical demonstrations.
- C. Use simulation activities.
- D. Incorporate verbal analogies.
Correct Answer: C
Rationale: Simulations enhance problem-solving skills.
The nurse has removed a barbiturate capsule from the unit dose wrapper to administer to a client. The client decides to watch a television program and requests not to take the medication. Which action should the nurse implement?
- A. Explain that since the medication is a controlled substance, it must be taken.
- B. Credit the medication back and put it in the client's medication box.
- C. Keep the medication and see if the client will want to take it later.
- D. Have another nurse witness the disposal of the medication into the disposal container.
Correct Answer: D
Rationale: Witnessed disposal prevents misuse of controlled substances.
History and Physical
The client is a 56-year-old woman who had an anteroposterior spinal fusion 2 days ago. She tolerated the procedure well and has been progressively increasing her walking distance.
Nurse’s Notes
12:00
Vital Signs:
• Heart rate: 98 beats/minute
• Pain rating: 5 on a 0 to 10 pain scale
Morphine 2.5 mg given IV push (IVP). The client ambulated twice with physical therapy.
13:00
Vital Signs:
• Heart rate: 78 beats/minute
• Pain rating: 3 on a 0 to 10 pain scale
Ibuprofen 800 mg given PO. The client is resting in bed.
14:00
Vital Signs:
• Heart rate: 118 beats/minute
• Pain rating: 8 on a 0 to 10 pain scale
Orders
• Up ad lib
• Regular diet
• Ibuprofen 800 mg PO every 8 hours for pain rated at 2 to 4 on a 0 to 10 pain scale
• Morphine 2.5 mg IV push every 4 hours for pain greater than 4 on a 0 to 10 pain scale
Based on the trending heart rate and pain score, what should the nurse do? Select all that apply.
- A. Assess for sources of pain other than the surgical site.
- B. Change to a behavioral pain scale.
- C. Give a dose of 2.5 mg of morphine.
- D. Refer to social work for drug-seeking behavior.
- E. Consult with the surgeon about the pain level.
- F. Helping the client walk around the room.
Correct Answer: A,C,E,F
Rationale: Choice A reason:
The increase in heart rate from 78 to 118 beats per minute, along with the increase in pain rating from 3 to 8, suggests that the client may be experiencing pain from a source other than the surgical site. It is important to assess for other potential sources of pain to ensure comprehensive pain management.
Choice B reason:
Changing to a behavioral pain scale is not indicated in this scenario. The numerical pain scale is a standard and effective method for assessing pain levels, and there is no indication that the client has difficulty communicating her pain using this scale.
Choice C reason:
Given that the client's pain rating increased to 8, which is above the threshold of 4 on the pain scale, administering a dose of 2.5 mg of morphine as per the orders is appropriate to manage her pain.
Choice D reason:
Referring to social work for drug-seeking behavior is not supported by the information provided. The client's increased pain rating and heart rate suggest a legitimate need for pain management rather than drug-seeking behavior.
Choice E reason:
Bringing an opioid reversal agent to the bedside is not indicated unless there is a concern for opioid overdose, which is not suggested by the information provided.
Choice F reason:
While guided imagery can be a helpful adjunct for pain management, it is not the primary intervention needed at this time given the client's significant increase in pain and heart rate.
Choice G reason:
Consulting with the surgeon about the client's increased pain level is important to rule out any complications from the surgery and to discuss further pain management strategies.
Choice H reason:
Assisting the client to walk around the room may help in pain management and is part of the postoperative care plan to increase walking distance. However, it should be done cautiously considering the client's current pain level.