66 Questions
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.
Why is it essential to remove the old fentanyl patch when applying a new one?
To avoid accidental overdose.
What would be the most successful cognitive-behavioral pain control method in the emergency department setting?
Listening to music on a headset
Why is listening to music on a headset considered a successful pain control method in the emergency department setting?
It does not require strong concentration.
Which nonpharmacologic pain control method may be challenging in an emergency department due to time constraints?
Guided imagery
Why might video games be less effective as a pain control method in an emergency department?
They require intense focus and concentration.
How does the simplicity of music therapy make it advantageous in an emergency department setting?
It is easy to implement without training.
Why might guided imagery be less suitable for clients in an emergency department setting?
It necessitates high levels of concentration.
What is the most important action by the nurse when discharging an older client living alone on opioid analgesics?
Request a home safety assessment.
For a client being discharged after surgery on hydrocodone and acetaminophen (Lorcet), what is the most important discharge instruction?
Check any over-the-counter medications for acetaminophen.
What is a common risk associated with acetaminophen use?
Liver damage
Why should an older client living alone be advised to have a home safety assessment when discharged on opioid analgesics?
To identify potential fall hazards.
What is an adverse effect that can result from exceeding the recommended daily dose of acetaminophen?
Liver failure
Why is it important for a client discharged on hydrocodone and acetaminophen to check over-the-counter medications?
To avoid potential interactions with acetaminophen.
What is a primary reason for advising a client on hydrocodone and acetaminophen to maintain their follow-up appointment with the surgeon?
To monitor for potential side effects or complications.
What action should the nurse take to prevent lymphedema in a client post-mastectomy?
Instruct the client to wear gloves when gardening outside.
Which factor could contribute to lymphedema besides radiation therapy?
Obesity
What symptoms may a client experience if they develop lymphedema after a mastectomy?
Heaviness, numbness, and swelling
What should the nurse emphasize to a client concerned about lymphedema after mastectomy?
Lymphedema symptoms are uncommon after mastectomy surgery.
Why is it important for the nurse to educate the client about infection prevention in relation to lymphedema?
Infection is a risk factor that can cause lymphedema.
Which statement about lymphedema is accurate?
Lymphedema may cause heaviness, aching, and swelling.
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?
Assess the client's bowel sounds.
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?
The stool will always be liquid with this type of colostomy.
What is the most appropriate way for the nurse to assist a client and her husband dealing with intimacy issues related to an ostomy?
Encourage them to openly discuss their concerns.
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?
To identify signs of peritonitis or perforation.
What is the significance of assessing for rebound tenderness in a client with a possible peritonitis related to bowel obstruction?
To assess for peritoneal irritation.
How does assessing for rebound tenderness differ from evaluating bowel sounds in a client with suspected peritonitis?
Bowel sounds are auscultated, while rebound tenderness is palpated.
Why should the nurse prioritize assessing for changes in abdominal pain nature and timing in a client with a bowel obstruction?
To detect critical complications like perforation or peritonitis.
What might be an essential role of an ostomy nurse in assisting clients and their partners with intimacy issues?
Providing psychological support during challenging times.
What could be the potential impact of nocturia on a client with benign prostatic hyperplasia?
Sleep interruptions leading to changes in mood and mental status.
How might incontinence affect a client's behavior and activities?
Can lead to embarrassment, restricting activities outside the home.
Why should a 55-year-old African-American client discuss the prostate-specific antigen test with their healthcare provider?
As an option for screening for prostate cancer, despite recommendations against routine screening.
What could be a consequence of social isolation due to incontinence in a client with benign prostatic hyperplasia?
Potential development of clinical depression.
How might nocturia impact the mental status of a client diagnosed with benign prostatic hyperplasia?
Lead to sleep disruptions affecting mood and mental status.
What advice should a nurse provide to a client experiencing nocturia related to benign prostatic hyperplasia?
Avoid consuming liquids after 6 pm to reduce nighttime trips to the bathroom.
How might social isolation due to incontinence impact a client's overall quality of life?
Lead to embarrassment and restrict activities outside the home.
What is the most accurate way to assess pain, according to the text?
Clients self-report
Why should a nurse believe a client's description of pain, as per the text?
Because physiologic changes due to pain are identical for all clients
In the context provided, why does the experienced nurse mention that 'Being able to sleep doesn't mean pain doesn't exist'?
To highlight that pain can sometimes allow sleep due to exhaustion
What does the text recommend as a response when a new nurse doubts a client's description of severe pain?
Believe the client and provide pain relief
What should be the nurse's approach when a client reports severe pain and then appears sound asleep?
Put back the medication as sleeping indicates no pain
Considering various ways to measure pain, what aspect makes a client's self-report the most reliable method?
Capacity to reflect the client's own experience accurately
What intervention is essential to manage breakthrough pain associated with specific procedures?
Using a client-controlled analgesia pump with basal and bolus settings
Why does pain control need to be continuous according to the text?
To avoid respiratory depression and extreme sedation
What is the primary concern when a client on a patient-controlled analgesia (PCA) pump has a respiratory rate of 8 breaths/min?
The potential for respiratory depression
Why should a client-controlled analgesia pump have both basal and bolus settings?
To achieve adequate pain control
What does a client-controlled analgesia pump with only an as-needed regimen fail to control according to the text?
Breakthrough pain associated with specific procedures
What should be the nurse's priority when assessing clients receiving patient-controlled analgesia (PCA) pumps?
Prioritizing clients with abnormal respiratory rates
Which intervention is most crucial for a hospitalized client using a transdermal fentanyl patch for chronic pain?
Removing the old patch when applying the new one
What would be the nurse's priority when initiating nonpharmacologic pain control methods in an emergency department?
Listening to music on a headset
In an emergency department setting, which action best promotes client safety during nonpharmacologic pain control interventions?
Allowing clients to listen to music on a headset
Why is it advisable to avoid using complex pain control methods like biofeedback in an emergency department setting?
Biofeedback requires advanced equipment not readily available
Which factor makes guided imagery less suitable for managing pain in an emergency department than listening to music on a headset?
Guided imagery's limited accessibility to clients
What makes playing video games less effective as a cognitive-behavioral pain control method in an emergency department setting?
Video games require a high level of concentration not feasible in acute settings
How can the nurse assist a client with mucositis to improve their nutrition?
Assist with rinsing the mouth with saline frequently.
What instructions should a nurse provide to a UAP assisting a client with thrombocytopenia?
Use a lift sheet when needed to reposition the client.
What diet selection should a nurse provide for a client who developed esophagitis after radiation therapy for lung cancer?
Chicken soup, grilled cheese sandwich
What actions should a nurse take when caring for a client with thrombocytopenia to prevent bleeding?
Instruct the UAP to assist with ambulation.
Why should a nurse avoid giving hot liquids to a client with mucositis?
Hot liquids may worsen the mucositis pain.
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?
Assess the client's skin surrounding the stoma.
What instruction should the nurse provide to a client hospitalized for chemotherapy with a hemoglobin of 6.1 mg/dL?
Prepare to administer Epoetin alfa (Epogen)
What is the most appropriate action by the nurse for a client with a platelet count of 9800/mm3?
Instruct the client to call for help to get out of bed
What is the priority action for a nurse assisting clients with alopecia from chemotherapy?
Helping clients adjust to their appearance
A client hospitalized for chemotherapy has severe neutropenia. What intervention should the nurse prioritize?
Preparing to administer Filgrastim (Neupogen)
What is the most suitable intervention for a hospitalized client experiencing bladder toxicity from chemotherapeutic agents?
Preparing to administer Mesna (Mesnex)
What is the appropriate care for a hospitalized client with low platelet count and calf pain, warmth, and redness?
Assessing for deep vein thrombosis symptoms
Learn about the most important action for client safety when a hospitalized client uses a transdermal fentanyl (Duragesic) patch for chronic pain. Test your knowledge on nursing care guidelines for clients using fentanyl patches.
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