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Questions and Answers

What is the most important action for the nurse to take when a new transdermal fentanyl patch is applied to a hospitalized client?

  • Remove the old patch when applying the new one. (correct)
  • Monitor the client's bowel function every shift.
  • Assess and record the client's pain every 4 hours.
  • Ensure the client is eating a high-fiber diet.
  • Why is it essential to remove the old fentanyl patch when applying a new one?

  • To avoid accidental overdose. (correct)
  • To prevent skin irritation.
  • To reduce the risk of infection at the application site.
  • To enhance pain relief effectiveness.
  • What would be the most successful cognitive-behavioral pain control method in the emergency department setting?

  • Listening to music on a headset (correct)
  • Participating in biofeedback
  • Playing video games
  • Using guided imagery
  • Why is listening to music on a headset considered a successful pain control method in the emergency department setting?

    <p>It does not require strong concentration.</p> Signup and view all the answers

    Which nonpharmacologic pain control method may be challenging in an emergency department due to time constraints?

    <p>Guided imagery</p> Signup and view all the answers

    Why might video games be less effective as a pain control method in an emergency department?

    <p>They require intense focus and concentration.</p> Signup and view all the answers

    How does the simplicity of music therapy make it advantageous in an emergency department setting?

    <p>It is easy to implement without training.</p> Signup and view all the answers

    Why might guided imagery be less suitable for clients in an emergency department setting?

    <p>It necessitates high levels of concentration.</p> Signup and view all the answers

    What is the most important action by the nurse when discharging an older client living alone on opioid analgesics?

    <p>Request a home safety assessment.</p> Signup and view all the answers

    For a client being discharged after surgery on hydrocodone and acetaminophen (Lorcet), what is the most important discharge instruction?

    <p>Check any over-the-counter medications for acetaminophen.</p> Signup and view all the answers

    What is a common risk associated with acetaminophen use?

    <p>Liver damage</p> Signup and view all the answers

    Why should an older client living alone be advised to have a home safety assessment when discharged on opioid analgesics?

    <p>To identify potential fall hazards.</p> Signup and view all the answers

    What is an adverse effect that can result from exceeding the recommended daily dose of acetaminophen?

    <p>Liver failure</p> Signup and view all the answers

    Why is it important for a client discharged on hydrocodone and acetaminophen to check over-the-counter medications?

    <p>To avoid potential interactions with acetaminophen.</p> Signup and view all the answers

    What is a primary reason for advising a client on hydrocodone and acetaminophen to maintain their follow-up appointment with the surgeon?

    <p>To monitor for potential side effects or complications.</p> Signup and view all the answers

    What action should the nurse take to prevent lymphedema in a client post-mastectomy?

    <p>Instruct the client to wear gloves when gardening outside.</p> Signup and view all the answers

    Which factor could contribute to lymphedema besides radiation therapy?

    <p>Obesity</p> Signup and view all the answers

    What symptoms may a client experience if they develop lymphedema after a mastectomy?

    <p>Heaviness, numbness, and swelling</p> Signup and view all the answers

    What should the nurse emphasize to a client concerned about lymphedema after mastectomy?

    <p>Lymphedema symptoms are uncommon after mastectomy surgery.</p> Signup and view all the answers

    Why is it important for the nurse to educate the client about infection prevention in relation to lymphedema?

    <p>Infection is a risk factor that can cause lymphedema.</p> Signup and view all the answers

    Which statement about lymphedema is accurate?

    <p>Lymphedema may cause heaviness, aching, and swelling.</p> Signup and view all the answers

    What action should the nurse take next if a client with a mechanical bowel obstruction reports constant abdominal pain an hour after experiencing intermittent pain?

    <p>Assess the client's bowel sounds.</p> Signup and view all the answers

    How should the nurse respond to a client who had a colostomy placed in the ascending colon 2 weeks ago and complains of liquid stool in the pouch?

    <p>The stool will always be liquid with this type of colostomy.</p> Signup and view all the answers

    What is the most appropriate way for the nurse to assist a client and her husband dealing with intimacy issues related to an ostomy?

    <p>Encourage them to openly discuss their concerns.</p> Signup and view all the answers

    In the context of a mechanical bowel obstruction, why should the nurse assess the client's bowel sounds when there is a change in abdominal pain nature and timing?

    <p>To identify signs of peritonitis or perforation.</p> Signup and view all the answers

    What is the significance of assessing for rebound tenderness in a client with a possible peritonitis related to bowel obstruction?

    <p>To assess for peritoneal irritation.</p> Signup and view all the answers

    How does assessing for rebound tenderness differ from evaluating bowel sounds in a client with suspected peritonitis?

    <p>Bowel sounds are auscultated, while rebound tenderness is palpated.</p> Signup and view all the answers

    Why should the nurse prioritize assessing for changes in abdominal pain nature and timing in a client with a bowel obstruction?

    <p>To detect critical complications like perforation or peritonitis.</p> Signup and view all the answers

    What might be an essential role of an ostomy nurse in assisting clients and their partners with intimacy issues?

    <p>Providing psychological support during challenging times.</p> Signup and view all the answers

    What could be the potential impact of nocturia on a client with benign prostatic hyperplasia?

    <p>Sleep interruptions leading to changes in mood and mental status.</p> Signup and view all the answers

    How might incontinence affect a client's behavior and activities?

    <p>Can lead to embarrassment, restricting activities outside the home.</p> Signup and view all the answers

    Why should a 55-year-old African-American client discuss the prostate-specific antigen test with their healthcare provider?

    <p>As an option for screening for prostate cancer, despite recommendations against routine screening.</p> Signup and view all the answers

    What could be a consequence of social isolation due to incontinence in a client with benign prostatic hyperplasia?

    <p>Potential development of clinical depression.</p> Signup and view all the answers

    How might nocturia impact the mental status of a client diagnosed with benign prostatic hyperplasia?

    <p>Lead to sleep disruptions affecting mood and mental status.</p> Signup and view all the answers

    What advice should a nurse provide to a client experiencing nocturia related to benign prostatic hyperplasia?

    <p>Avoid consuming liquids after 6 pm to reduce nighttime trips to the bathroom.</p> Signup and view all the answers

    How might social isolation due to incontinence impact a client's overall quality of life?

    <p>Lead to embarrassment and restrict activities outside the home.</p> Signup and view all the answers

    What is the most accurate way to assess pain, according to the text?

    <p>Clients self-report</p> Signup and view all the answers

    Why should a nurse believe a client's description of pain, as per the text?

    <p>Because physiologic changes due to pain are identical for all clients</p> Signup and view all the answers

    In the context provided, why does the experienced nurse mention that 'Being able to sleep doesn't mean pain doesn't exist'?

    <p>To highlight that pain can sometimes allow sleep due to exhaustion</p> Signup and view all the answers

    What does the text recommend as a response when a new nurse doubts a client's description of severe pain?

    <p>Believe the client and provide pain relief</p> Signup and view all the answers

    What should be the nurse's approach when a client reports severe pain and then appears sound asleep?

    <p>Put back the medication as sleeping indicates no pain</p> Signup and view all the answers

    Considering various ways to measure pain, what aspect makes a client's self-report the most reliable method?

    <p>Capacity to reflect the client's own experience accurately</p> Signup and view all the answers

    What intervention is essential to manage breakthrough pain associated with specific procedures?

    <p>Using a client-controlled analgesia pump with basal and bolus settings</p> Signup and view all the answers

    Why does pain control need to be continuous according to the text?

    <p>To avoid respiratory depression and extreme sedation</p> Signup and view all the answers

    What is the primary concern when a client on a patient-controlled analgesia (PCA) pump has a respiratory rate of 8 breaths/min?

    <p>The potential for respiratory depression</p> Signup and view all the answers

    Why should a client-controlled analgesia pump have both basal and bolus settings?

    <p>To achieve adequate pain control</p> Signup and view all the answers

    What does a client-controlled analgesia pump with only an as-needed regimen fail to control according to the text?

    <p>Breakthrough pain associated with specific procedures</p> Signup and view all the answers

    What should be the nurse's priority when assessing clients receiving patient-controlled analgesia (PCA) pumps?

    <p>Prioritizing clients with abnormal respiratory rates</p> Signup and view all the answers

    Which intervention is most crucial for a hospitalized client using a transdermal fentanyl patch for chronic pain?

    <p>Removing the old patch when applying the new one</p> Signup and view all the answers

    What would be the nurse's priority when initiating nonpharmacologic pain control methods in an emergency department?

    <p>Listening to music on a headset</p> Signup and view all the answers

    In an emergency department setting, which action best promotes client safety during nonpharmacologic pain control interventions?

    <p>Allowing clients to listen to music on a headset</p> Signup and view all the answers

    Why is it advisable to avoid using complex pain control methods like biofeedback in an emergency department setting?

    <p>Biofeedback requires advanced equipment not readily available</p> Signup and view all the answers

    Which factor makes guided imagery less suitable for managing pain in an emergency department than listening to music on a headset?

    <p>Guided imagery's limited accessibility to clients</p> Signup and view all the answers

    What makes playing video games less effective as a cognitive-behavioral pain control method in an emergency department setting?

    <p>Video games require a high level of concentration not feasible in acute settings</p> Signup and view all the answers

    How can the nurse assist a client with mucositis to improve their nutrition?

    <p>Assist with rinsing the mouth with saline frequently.</p> Signup and view all the answers

    What instructions should a nurse provide to a UAP assisting a client with thrombocytopenia?

    <p>Use a lift sheet when needed to reposition the client.</p> Signup and view all the answers

    What diet selection should a nurse provide for a client who developed esophagitis after radiation therapy for lung cancer?

    <p>Chicken soup, grilled cheese sandwich</p> Signup and view all the answers

    What actions should a nurse take when caring for a client with thrombocytopenia to prevent bleeding?

    <p>Instruct the UAP to assist with ambulation.</p> Signup and view all the answers

    Why should a nurse avoid giving hot liquids to a client with mucositis?

    <p>Hot liquids may worsen the mucositis pain.</p> Signup and view all the answers

    What is an appropriate action for the nurse when a client complains of liquid stool in the pouch 2 weeks after having a colostomy placed?

    <p>Assess the client's skin surrounding the stoma.</p> Signup and view all the answers

    What instruction should the nurse provide to a client hospitalized for chemotherapy with a hemoglobin of 6.1 mg/dL?

    <p>Prepare to administer Epoetin alfa (Epogen)</p> Signup and view all the answers

    What is the most appropriate action by the nurse for a client with a platelet count of 9800/mm3?

    <p>Instruct the client to call for help to get out of bed</p> Signup and view all the answers

    What is the priority action for a nurse assisting clients with alopecia from chemotherapy?

    <p>Helping clients adjust to their appearance</p> Signup and view all the answers

    A client hospitalized for chemotherapy has severe neutropenia. What intervention should the nurse prioritize?

    <p>Preparing to administer Filgrastim (Neupogen)</p> Signup and view all the answers

    What is the most suitable intervention for a hospitalized client experiencing bladder toxicity from chemotherapeutic agents?

    <p>Preparing to administer Mesna (Mesnex)</p> Signup and view all the answers

    What is the appropriate care for a hospitalized client with low platelet count and calf pain, warmth, and redness?

    <p>Assessing for deep vein thrombosis symptoms</p> Signup and view all the answers

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