thirty minutes after receiving iv morphine a postoperative client continues to rate pain as 7 on a 10 point scale which action should the pn implement
Logo

Nursing Elites

HESI LPN

HESI PN Exit Exam 2023

1. Thirty minutes after receiving IV morphine, a postoperative client continues to rate pain as 7 on a 10-point scale. Which action should the PN implement first?

Correct answer: C

Rationale: The most appropriate action for the PN to implement first is to implement complementary pain relief methods. This includes repositioning the client, applying heat or cold packs, or using relaxation techniques. These strategies can provide additional pain relief before the next dose of medication is due or before seeking further instructions from the healthcare provider. Calling the healthcare provider immediately to request a different analgesic (Choice A) may not be necessary at this moment since other non-pharmacological methods can be attempted first. Determining when morphine can be given again (Choice B) is important but addressing the client's immediate pain relief takes precedence. Observing the dressing for bleeding (Choice D) is important but not the first priority when the client is experiencing unrelieved pain.

2. The client with schizophrenia who continues to repeat the last words heard is exhibiting a sign of disturbed thought processes. Which nursing problem should the nurse document in the medical record?

Correct answer: D

Rationale: The correct answer is D: Disturbed thought processes. Echolalia, the repetition of words, is a sign of disturbed thought processes commonly seen in clients with schizophrenia. It reflects a disorganization in thinking rather than a sensory perception issue (Choice A). Impaired social interaction (Choice B) refers to difficulties in relating to others, which is not the primary concern in echolalia. Risk for self-directed violence (Choice C) focuses on potential harm to self, which is separate from the repetitive behavior of echolalia.

3. A 50-year-old female is in the hospital with peripheral artery disease. In the nursing care plan, the nurse lists the following nursing diagnosis: Ineffective tissue perfusion: peripheral related to venous stasis. Which of the following would not be an appropriate nursing action to list in the implementation of this diagnosis?

Correct answer: A

Rationale: Keeping the client’s extremities cold would worsen perfusion issues and is not recommended. In peripheral artery disease, maintaining warmth is crucial to promote vasodilation and improve blood flow. Checking peripheral pulses for strength and symmetry, keeping the client's legs elevated to reduce venous stasis, and monitoring for constrictions that may impair circulation are appropriate nursing actions to enhance tissue perfusion in this case. Thus, option A is incorrect as it would hinder perfusion in the affected extremities.

4. What is the primary purpose of administering Rho(D) immune globulin (RhoGAM) to an Rh-negative mother after childbirth?

Correct answer: A

Rationale: The correct answer is A: To prevent Rh sensitization in future pregnancies. RhoGAM is given to an Rh-negative mother to prevent the development of antibodies against Rh-positive blood cells. This prevents Rh sensitization, which could lead to hemolytic disease in future Rh-positive pregnancies. Choices B, C, and D are incorrect because RhoGAM is not used to treat anemia in the newborn, increase the mother's white blood cell count, or prevent infection in the newborn.

5. Which of the following is a priority for the nurse to include in the teaching of a client who was recently prescribed alprazolam (Xanax) as an oral medication?

Correct answer: D

Rationale: The correct answer is D: 'Avoid alcohol.' Alprazolam (Xanax) can have central nervous system depressant effects, which are exacerbated by alcohol. It is crucial to avoid alcohol while taking this medication to prevent severe sedation and respiratory depression. Monitoring heart rate (choice A) is not directly related to alprazolam administration. Monitoring temperature daily (choice B) is not a priority teaching point for a client prescribed alprazolam. Avoiding unprotected exposure to sunlight (choice C) is not specifically linked to the use of alprazolam.

Similar Questions

When caring for a patient with a fresh tracheostomy, what is the nurse’s first priority?
After a laparoscopic cholecystectomy, what is the most important instruction the nurse should give the client regarding post-operative care at home?
A client is post-operative day two from an abdominal surgery and reports feeling weak and lightheaded when attempting to get out of bed. What is the nurse's priority action?
During a routine prenatal visit at the antepartal clinic, a multipara at 35-weeks gestation presents with 2+ edema of the ankles and feet. Which additional information should the PN report to the RN?
A client post-coronary artery bypass graft (CABG) surgery is concerned about the risk of infection. What is the most important preventive measure the nurse should emphasize during discharge teaching?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses