Nokea
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.
You may also like to solve these questions
The nurse is reviewing the signed operative consent with a client who is admitted for the removal of a lipoma on the left leg. The client reports the permit should include another lipoma on the right leg. Which action should the nurse implement?
- A. Have the client sign a new surgical permit.
- B. Inform the surgeon about the client's concern.
- C. Add the additional information to the permit.
- D. Notify the surgical staff of the client's confusion.
Correct Answer: B
Rationale: Surgeon must evaluate and amend consent.
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.
A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. When caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?
- A. Stethoscope.
- B. Bed linens.
- C. Sputum specimen.
- D. Paper mask and gown.
Correct Answer: D
Rationale: Disposable PPE prevents contamination.
History and Physical
2/15/2021
The patient is a 36-year-old female who is in the clinic today for insomnia. She reports that she started having trouble sleeping over a year ago after her father’s death. She has no medical problems and has never had surgery. She takes an oral contraceptive and a multivitamin daily. She does not smoke but drinks one to two glasses of wine every evening.
Nurse’s Notes
2/15/2021
Vital Signs:
• Temperature: 97°F (36.1°C) orally
• Heart rate: 59 beats/minute
• Respiratory rate: 16 breaths/minute
• Blood pressure: 116/72 mm Hg
Educated the patient on sleep hygiene techniques, such as avoiding exercise and caffeine right before bed.
3/2/2021
The patient is in the clinic following up after her sleep study, which showed no signs of sleep apnea. The patient continues to have poor sleep even with eliminating caffeine and doing a relaxing activity before bed, such as yoga. The patient will keep a sleep journal to document her sleep for the next 2 weeks.
3/16/2021
The patient completed a 2-week sleep journal. The patient falls asleep 1 to 2 hours after going to bed and wakes up 2 to 3 times per night. She does not have to use the restroom during the night. She experiences daytime drowsiness and headaches nowadays.
Orders
2/15/2021
Sleep study for 1 night.
What other recommendations could the nurse give to help the patient have better sleep? Select all that apply.
- A. Exercise in the evening
- B. Watch television in bed to fall asleep.
- C. Take an analgesic before bed.
- D. Avoid alcohol in the evening.
- E. Try to go to bed and awaken at the same time every day.
- F. Avoid naps.
- G. Eat a heavy meal before bed.
Correct Answer: D,E,F
Rationale: Choice A reason:
Exercising in the evening can actually be counterproductive for some people when it comes to sleep. While regular exercise is beneficial for overall health and can contribute to better sleep, doing it too close to bedtime can stimulate the body, making it harder to relax and fall asleep.
Choice B reason:
Watching television in bed is generally not recommended as part of good sleep hygiene. The light from the screen can interfere with the body's production of melatonin, the hormone that signals it's time to sleep, and engaging content can keep the brain alert rather than allowing it to wind down.
Choice C reason:
Taking an analgesic before bed is not a general recommendation for better sleep unless pain is a specific issue that is preventing sleep. It's important to address the root cause of insomnia rather than masking symptoms with medication.
Choice D reason:
Avoiding alcohol in the evening is a good practice for better sleep. Alcohol can disrupt the sleep cycle and lead to fragmented sleep, even though it may initially seem to help with falling asleep.
Choice E reason:
Going to bed and waking up at the same time every day helps to regulate the body's internal clock, or circadian rhythm, which can improve sleep quality. Consistency is key for this practice to be effective.
Choice F reason:
Avoiding naps, especially in the late afternoon or evening, can help ensure that you are sufficiently tired at bedtime. Napping can interfere with nighttime sleep if done too late in the day or for too long.
Choice G reason:
Eating a heavy meal before bed can lead to discomfort and indigestion, which can make it harder to fall asleep. It's best to have a light snack if needed and avoid large meals close to bedtime.
A client who is 2 days postoperative for thoracic surgery is reporting incisional pain 2 hours after receiving pain medication. The client rates the pain as 5 on a pain scale of 0 to 10. After placing a call to the healthcare provider, which action should the nurse implement?
- A. Provide at least 20 minutes of back massage and gentle efleurage.
- B. Instruct the client to use guided imagery and slow rhythmic breathing.
- C. Place a hot water circulation device, such as an aquathermia pad, on the operative site.
- D. Tune to a television show or easy listening music to provide distraction.
Correct Answer: A
Rationale: Massage complements pain management.