Nur 255 B Adult Health 1 CBU

Correct Answer: Explain that physical dependence on pain medication is uncommon during the short-term postoperative period.

In the short-term postoperative period, the goal is to manage the patient's pain adequately to promote healing and comfort. Physical dependence can develop when a person uses pain medication over a long period, but it is not typically a concern in short-term use after surgery.

Addiction, which involves psychological cravings and compulsive behavior to misuse substances, is also rare when the medication is prescribed appropriately and used for its intended purpose.

By explaining this to the patient, the nurse can help alleviate concerns about addiction while providing the necessary support for pain management. This approach also addresses the patient’s concern about becoming addicted while ensuring they understand that physical dependence does not automatically equate to addiction.

Why the Other Options Are Wrong:

This patient must already have an addiction problem

The nurse should not assume that the patient has an addiction problem. The patient’s fear of becoming addicted might stem from a misunderstanding of pain medications and addiction. Jumping to conclusions without evidence of addiction can make the patient feel stigmatized and less likely to be open about their concerns.

This patient might benefit from a placebo dose

Giving a placebo (inactive treatment) is unethical and can break trust between the nurse and the patient. It also does not address the real issue, which is the patient’s concern about becoming addicted. Proper pain management involves using real medications that are both effective and appropriate for the patient’s condition, as well as providing reassurance and education.

The physician must be notified to discuss pain management

While it’s important to involve the physician if there are concerns about pain management, this is not the first action in this scenario. The nurse can address the patient’s concerns about addiction by educating them and discussing the short-term use of pain medication. Involving the physician right away may delay addressing the patient's immediate fears and concerns.

Summary:

The patient’s concern about addiction is common and can be addressed by educating them about the low risk of addiction with short-term postoperative pain management. The correct approach is to reassure the patient, explain the difference between physical dependence and addiction, and emphasize that proper pain control is important for recovery. It’s crucial not to jump to conclusions about addiction or use unethical practices like placebos, and notifying the physician is not necessary unless further complications arise. This approach can improve the nurse-patient relationship and encourage proper pain management.

Correct Answer: 1-2 weeks

The oliguric stage of acute kidney injury (AKI) typically lasts 1-2 weeks. During this stage, the kidneys are not able to effectively filter waste products from the bloodstream, and the patient may experience oliguria, or significantly reduced urine output.

This stage is characterized by a decrease in urine production and the retention of waste, leading to imbalances in electrolytes, acid-base status, and fluid volume.

The duration can vary, but generally, the oliguric phase lasts between 1 and 2 weeks, depending on the severity of the injury and the patient's response to treatment.

Why the other options are wrong:

1-3 days

This is incorrect because the oliguric phase typically lasts longer than just a few days. While some patients may progress through this stage more quickly, it usually lasts longer, around 1-2 weeks.

Few hours to 2 weeks

This option is not entirely wrong in that the stage could last anywhere from a few hours to two weeks, but it is too broad and not specific enough. The majority of patients will remain in the oliguric phase for 1-2 weeks, so this range may cause confusion.

12 months

This is incorrect because the oliguric phase of AKI does not last anywhere near that long. The oliguric stage is typically a short-term phase, lasting days to weeks, but not months. If the condition persists for such an extended period, it may indicate chronic kidney disease (CKD) or end-stage kidney disease (ESKD), not AKI.

Summary:

The oliguric phase in acute kidney injury usually lasts between 1-2 weeks, during which time kidney function is impaired, leading to reduced urine output and the accumulation of waste products. This stage requires close monitoring and intervention to correct electrolyte imbalances, fluid overload, and potential acidosis.

The correct duration of this phase is important for the timely identification of the transition to the diuretic phase, where the kidneys start to recover and produce more urine.

Correct Answer: Prevent intra- and postoperative deep vein thrombosis

Sequential compression devices (SCDs) are primarily used to prevent deep vein thrombosis (DVT), which is a clot that can form in the veins, especially in the legs, during periods of immobility such as surgery.

These devices work by inflating and deflating in a rhythmic pattern, promoting blood flow in the legs and reducing the risk of clot formation.

Why the Other Options Are Incorrect:

Improve circulation prior to surgery:

While SCDs do promote circulation, their primary purpose is not to improve circulation prior to surgery but to prevent DVT during and after surgery when the patient is immobile.

Assist in keeping the client warm during surgery:

SCDs are not designed to keep a client warm. There are other devices, such as warming blankets, that help maintain body temperature during surgery.

Promote dehiscence and wound healing postoperatively:

SCDs do not promote dehiscence (wound reopening). Their primary function is to prevent blood clots, not to influence wound healing or dehiscence.

Summary:

The primary purpose of sequential compression devices (SCDs) is to prevent intra- and postoperative deep vein thrombosis (DVT) by promoting circulation in the legs during periods of immobility.

The correct Answer: "Exercise should be avoided due to the physical stress it causes on the body."

In patients with Systemic Lupus Erythematosus (SLE), physical activity is generally beneficial and can help improve overall health, reduce inflammation, and manage stress.

While overexertion or intense physical activity can sometimes contribute to fatigue or joint pain, moderate exercise is encouraged as part of a healthy lifestyle.

It is important to focus on moderation and avoid excessive strain, but exercise should not be avoided entirely unless there are specific contraindications, like an active flare or complications.

Why the other options are correct:

"Emotional stress and illness are triggers for a flare-up.":

Emotional stress and illness (like infections) are well-known triggers for lupus flares. Reducing stress and avoiding illness (through proper hygiene and vaccinations) are important strategies for preventing flare-ups.

"I always wear large-brimmed hats and long sleeves when I'm outside.":

Sun exposure is a known trigger for lupus flares, and wearing protective clothing like large-brimmed hats and long sleeves, along with sunscreen, is a key preventive measure for managing the condition

"I will make it priority to receive my yearly influenza vaccine.":

Vaccination, including the annual influenza vaccine, is important for preventing infections, which can trigger lupus flares. Patients with lupus should work with their healthcare provider to ensure they are up-to-date on vaccinations, including flu shots.

Summary:

Re-education is needed for the statement regarding exercise. Exercise, when done moderately, is typically encouraged for SLE patients. It is important for patients to understand that exercise does not need to be avoided but should be adapted to their individual capabilities and symptoms.

Correct Answer: Pre-renal

In the case of a massive GI bleed, the patient is at risk for pre-renal acute kidney injury (AKI). This is due to the following reasons:

Pre-renal AKI occurs when there is reduced blood flow to the kidneys, often due to hypovolemia (low blood volume), which can happen in the setting of a massive GI bleed. |

When significant blood is lost, the body compensates by shunting blood away from the kidneys to more vital organs.

This decreased renal perfusion leads to acute kidney injury. In the absence of sufficient blood flow, the kidneys cannot filter waste products effectively, leading to kidney dysfunction.

Why the other options are incorrect:

Post-renal AKI:

Post-renal AKI occurs when there is an obstruction in the urinary tract after the kidneys, such as from kidney stones or an enlarged prostate. This does not apply to a GI bleed scenario, which typically affects kidney perfusion due to hypovolemia.

Intra-renal AKI:

Intra-renal AKI (also called intrinsic renal AKI) is caused by direct damage to the kidneys themselves, such as in cases of glomerulonephritis, acute tubular necrosis, or interstitial nephritis. While prolonged ischemia from poor perfusion could cause damage to kidney tissue, it is more directly classified as pre-renal AKI.

Intrinsic renal AKI:

This type of AKI is due to damage directly to the kidney tissue (e.g., the glomeruli or tubules). While a massive GI bleed could eventually lead to intrinsic damage if perfusion is not restored, initially, the AKI would be considered pre-renal due to reduced blood flow.

Summary:

A massive GI bleed can lead to pre-renal acute kidney injury due to hypovolemia (decreased blood volume), which results in reduced renal perfusion. The kidneys are unable to filter effectively because of this lack of adequate blood flow. 

Correct Answer: Temperature

The most concerning finding is the temperature of 101°F, which indicates a fever.

In a patient with type 2 diabetes mellitus, a fever can signal an infection, which is a common complication in individuals with diabetes due to their impaired immune response and the potential for slower wound healing or other infections.

Infections can lead to elevated blood glucose levels and, if not addressed, can result in complications such as diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). Therefore, the fever requires prompt assessment to identify the source of infection and initiate treatment.

Why the Other Options Are Incorrect:

Pulse of 88 bpm:

A pulse of 88 beats per minute is within the normal range for an adult (60-100 bpm). Although a slight increase in heart rate can occur with fever or infection, this pulse rate is not concerning by itself.

Blood pressure of 100/72:

This blood pressure is within normal limits for most adults. A blood pressure of 100/72 is not dangerously low and would not be a primary concern at this time.

Respirations of 22 breaths per minute:

A respiratory rate of 22 bpm is within the normal adult range (12-20 bpm), though slightly elevated. The increased respiratory rate could be a response to fever or infection but is not alarming by itself unless there are signs of respiratory distress or other complications such as ketoacidosis.

Summary:

The temperature of 101°F is the most concerning finding because it indicates the potential for an infection, which could complicate the management of diabetes. The nurse should focus on identifying the source of the infection and treating it promptly to avoid further complications, including those that could affect blood glucose levels. The other vital signs are within normal or acceptable ranges for the patient at this moment.

Correct Answer: The patient may be in pain

After abdominal surgery, increased blood pressure and restlessness are common signs of postoperative pain. Pain stimulates the sympathetic nervous system, leading to increased blood pressure, heart rate, and restlessness. Since the patient's oxygen saturation is 97%, hypoxia is unlikely to be the cause of these symptoms. Pain should always be assessed as a priority in postoperative patients.

Why the Other Options Are Wrong:

The patient is hypothermic 

Hypothermia may cause shivering, which can increase oxygen consumption, but it typically does not lead to significant increases in blood pressure or restlessness. The question does not indicate a low temperature or shivering.

The patient is in shock 

Shock is characterized by hypotension, tachycardia, and decreased perfusion, which are not present here. Increased blood pressure is not consistent with shock.

The patient is hypoxic 

Hypoxia is unlikely given the patient’s oxygen saturation of 97%, which indicates adequate oxygenation.

Summary:

Increased blood pressure and restlessness in a postoperative patient with normal oxygen saturation most likely indicate pain, which should be assessed and managed as a priority.

Correct Answer: Morphine 1 mg IV as needed for pain

While morphine is commonly used for pain management, it should be used cautiously in patients with acute pancreatitis.

Morphine has the potential to spasm the sphincter of Oddi, which can increase pressure within the pancreatic duct and exacerbate pain in patients with pancreatitis.

Fentanyl or hydromorphone are typically preferred for pain management in pancreatitis because they do not have the same effect on the sphincter of Oddi.

Why the Other Options Are Incorrect:

"Insert nasogastric tube":

A nasogastric (NG) tube is often used in acute pancreatitis to decompress the stomach and prevent further gastric distention. It is used to manage nausea and vomiting and to reduce pancreatic stimulation. This is a standard intervention for acute pancreatitis and is appropriate.

"IV infusion of 0.9NS at 100cc/hr":

Fluid resuscitation is a critical part of managing acute pancreatitis. Patients often become hypovolemic due to fluid shifts and third-space losses, so maintaining hydration is essential. Normal saline (0.9% NaCl) is a common choice for IV fluid replacement. The infusion rate of 100cc/hr is appropriate for maintaining hydration without causing fluid overload.

"Clear liquid diet":

A clear liquid diet is often recommended in the early stages of acute pancreatitis to allow the pancreas to rest. This diet helps prevent stimulating pancreatic secretion, which can worsen inflammation. Once the patient improves and pain decreases, they may be advanced to a full liquid diet and then regular food.

Summary:

The physician's order for morphine should be questioned in a patient with acute pancreatitis because it can worsen pain by causing spasms of the sphincter of Oddi. Other orders, such as inserting an NG tube for decompression, administering IV fluids for hydration, and starting a clear liquid diet, are appropriate for managing acute pancreatitis.

Correct Answer: Assessment for respiratory depression.

Morphine, like other opioids, can cause respiratory depression as a side effect, especially when administered in high doses or via a patient-controlled analgesia (PCA) pump.

This effect is potentially life-threatening, particularly after an initial bolus dose, which delivers a larger amount of medication in a short time. The priority assessment is to closely monitor the patient's respiratory rate, depth, and oxygen saturation after receiving the bolus to ensure that respiratory depression does not occur.

Why the other options are wrong:

Assessment for confusion:

Confusion can occur with opioid use, especially in elderly patients, but it is not the most immediate risk after an initial bolus dose. Respiratory depression takes precedence because it can quickly become life-threatening if not addressed immediately.

Assessment for fluid overload:

Fluid overload is not a common issue related to morphine administration, and it is not the most immediate concern following a bolus dose. The primary concern with morphine is its respiratory effects, not fluid balance.

Assessment for paradoxical (inexplicable) increase in pain:

While it's important to assess for ineffective pain management, a paradoxical increase in pain is less common than respiratory depression following an opioid bolus. Monitoring respiratory function is the highest priority due to the acute risks of respiratory compromise.

Summary:

After administering an initial bolus dose of morphine via a PCA pump, the nurse’s priority is to assess for respiratory depression, as this is the most immediate and potentially life-threatening side effect of opioid administration.