NR-226 Patient Care Fundamentals - Set 4 - Part 2

Correct Answer: Reassess the pain and contact the provider

Clock-watching in a client whose pain stays above the goal points to an inadequate regimen rather than addiction. The nurse reassesses and reports the unrelieved pain so the dose, interval or drug can be changed. Option a is incorrect because addiction is identified by impaired control, craving and continued use despite harm, none of which appears here. Labeling an undertreated postoperative client in the record shapes how every later caregiver responds. Option b is incorrect because withholding an ordered dose to see what happens is neither an assessment nor a treatment. It leaves the client in pain, damages trust, and produces no information the nurse could act on. Option c is incorrect because physical dependence shows itself through withdrawal when a drug stops abruptly, and it takes longer than two postoperative days to matter. Naming it here explains nothing about pain that remains above goal.

Correct Answer: "I will put a night light on the bathroom path."

Slower dark adaptation and a smaller pupil make the night trip to the bathroom a common fall event. Lighting that path lets the eyes work with the information they still have. Option a is incorrect because throw rugs are a leading extrinsic hazard, catching the toe of a shortened shuffling stride. Warmth is worth having, but it must not come from a loose edge on a walking path. Option c is incorrect because socks alone on a hard floor slide. Fall prevention calls for well-fitting closed-back shoes with a low heel and a non-skid sole, worn whenever the client is up. Option d is incorrect because furniture walking removes the stable base a fitted walker provides. Chairs slide, tables tip, and reaching for one means she has already lost the balance she was trying to protect.

Correct Answer: Face her in good light with lower pitch

Presbycusis takes the high frequencies first, so consonants disappear while volume is still heard. Seeing the speaker's lips in good light and hearing a lower pitch restores the sounds that carry meaning. Option b is incorrect because shouting distorts sound and pushes the voice higher, into the range she has already lost. Repeating identical words gives her nothing new to decode, so rephrasing works better than volume. Option c is incorrect because a raised pitch moves speech further out of her hearing range and over-articulating distorts lip shapes. Slowing alone helps only when the pitch and the visual cues also support her. Option d is incorrect because routing instructions through a relative sidelines the adult who owns the decision. That habit is a recognized form of ageism, and it also leaves the nurse without confirmation that she understood.

Correct Answer: I will read every label for acetaminophen or APAP.

Acetaminophen is hidden in more than six hundred products, including opioid combinations, cold and sinus preparations and sleep aids. Reading every label for acetaminophen or APAP is how the client keeps the daily total safe. Option a is incorrect because the largest share of accidental overdose comes from nonprescription bottles the client never counted. Checking only the prescription label leaves the cold remedy and the headache tablets unaccounted for. Option c is incorrect because spacing doses does not reduce the twenty four hour total, which is the number that determines hepatic injury. Stacking sources across a day is precisely how liver failure happens. Option d is incorrect because multisymptom cold, flu and sinus preparations routinely list acetaminophen among their active ingredients. Believing otherwise is what allows a client to exceed the ceiling without ever intending to.

Correct Answer: I will avoid hot baths and call about any fever.

External heat and fever increase absorption from the patch and can produce an overdose. Teaching the client to avoid heating pads, hot baths and saunas, and to report fever, is a core safety instruction. Option a is incorrect because a heating pad over the patch raises skin blood flow and drives more fentanyl into the circulation. Deaths have followed exactly this combination of heat and patch. Option b is incorrect because cutting a patch destroys the delivery system and can release the whole reservoir at once. Dose adjustment belongs to the prescriber, who changes the patch strength instead. Option d is incorrect because two patches worn together double the delivered dose. The old system must be removed and its removal documented, since patches lost in bedding have poisoned children and pets.

Correct Answer: Hold the codeine and contact the prescriber

The FDA contraindicates codeine and tramadol after tonsillectomy or adenoidectomy in anyone under eighteen, because ultrarapid metabolizers convert codeine to dangerously high morphine levels. The nurse withholds the drug and asks for a different order. Option a is incorrect because food changes only gastrointestinal tolerance, not the metabolic problem. A child who converts codeine rapidly reaches toxic morphine concentrations whether or not the tablet was taken with a meal. Option b is incorrect because monitoring does not make a contraindicated drug safe. Airway swelling after tonsillectomy already narrows the airway, and adding an opioid the child may overconvert has caused pediatric deaths. Option c is incorrect because a nurse cannot alter a prescribed dose, and halving it would not remove the genetic risk. The unpredictable variable is the child's CYP2D6 activity, not the amount swallowed.

Correct Answer: Administer the ordered analgesic and reassess afterward

Self-report is the most reliable indicator of pain, and behavior such as laughing is a coping strategy rather than proof of comfort. The nurse accepts the report and treats the pain as ordered. Option b is incorrect because appearance is supplementary data that supports a pain report when present but never refutes one. Charting an impression of comfort in place of the client's rating misrepresents the assessment and delays relief. Option c is incorrect because delaying medication for a visit adds nothing clinically and lets the pain climb, which makes it harder to control. Family presence actually lowers reported pain and should be encouraged, not treated as an obstacle. Option d is incorrect because there is no inconsistency to report. Normal behavior alongside a high rating is common, and calling the provider about it substitutes the nurse's judgment for the client's own account of the experience.

Correct Answer: Stop the morphine and support ventilation

Unarousable somnolence with slow shallow breathing is the highest sedation level on the Pasero scale. The required action is to stop the opioid, open the airway and support ventilation while naloxone is considered. Option a is incorrect because a dose reduction belongs to the level below this one, where the client is drowsy but still rousable. Reducing rather than stopping leaves opioid running into an unresponsive client. Option b is incorrect because drawing a blood gas confirms hypoventilation the nurse can already see. Sending a specimen consumes minutes during which no oxygen reaches the client, and the treatment would not change. Option d is incorrect because repositioning may protect the airway but does nothing about the opioid still being delivered. Airway protection alone will not restore ventilation in a client this deeply sedated.

Correct Answer: Guide the client calmly back toward bed

Waking a sleepwalker abruptly out of deep sleep produces confusion and sometimes combative behavior, and the risk of a fall rises. Gentle redirection returns the client to bed while keeping the environment safe. Option a is incorrect because forcible waking is the classic wrong answer here. It sounds like attentive nursing, yet dragging someone out of the deepest stage leaves them disoriented, frightened and liable to lash out. Option b is incorrect because summoning security treats a sleep phenomenon as a behavioral disturbance and delays the simple redirection that resolves it. Extra strangers and commotion add stimulation the client does not need. Option c is incorrect because an unsupervised sleepwalker on an unfamiliar unit can reach a stairwell, an exit or a piece of equipment. Safety, not wakefulness, is the goal, and it requires the nurse to stay.

Correct Answer: Report the episode and expect the drug discontinued

Complex sleep behaviors carry a boxed warning for this drug class, and any such episode makes further use contraindicated. The nurse reports it promptly so the prescriber can discontinue the medication and address safety. Option a is incorrect because the client performed a complicated task while not fully awake, which is far removed from dreaming. Treating a reportable adverse event as normal leaves him at risk of serious injury. Option c is incorrect because timing changes address next-morning grogginess, not sleep-related eating or driving. Shifting the hour does nothing about a reaction that permanently rules the medication out for this client. Option d is incorrect because food actually delays absorption and weakens the intended effect, so the advice works against the prescription. More importantly, no dosing adjustment makes a complex sleep behavior acceptable.

Correct Answer: The internal clock is signaling wakefulness then

The master clock in the hypothalamus drives alertness during daylight, so sleep attempted then is shorter and lighter. The worker is sleeping against her own rhythm rather than with it. Option b is incorrect because sleep pressure accumulates during every hour of wakefulness regardless of the clock on the wall. A night worker finishes a shift with a large debt, which is why she is exhausted. Option c is incorrect because the opposite happens. Sleep taken during the biological day is lighter and more fragmented, with less of the deep restorative stage, which is precisely the source of her complaint. Option d is incorrect because melatonin is the chemical announcement of darkness. Light striking the retina suppresses it, so morning sunlight on the drive home drives melatonin down instead of up.

Correct Answer: Referred pain from a visceral organ

Referred pain is felt at a site distant from its source because visceral afferents converge with somatic afferents in the same spinal segments. Gallbladder disease classically refers to the right shoulder and scapula. Option a is incorrect because phantom pain occurs in a body part that has been amputated. This client has an intact shoulder and an inflamed organ, so nothing here matches the amputation picture. Option c is incorrect because breakthrough pain is a flare that erupts through an otherwise controlled baseline regimen. No scheduled analgesic has been described, and the location itself is what identifies the finding here. Option d is incorrect because damage to the nervous system itself produces burning, shooting or electric sensations along a nerve distribution. A deep ache from an inflamed organ is nociceptive visceral pain that happens to refer.

Correct Answer: Stage N3, known as slow-wave sleep

N3, the deep slow-wave stage, produces the largest growth hormone pulse of the night and is when protein synthesis, cell division and tissue repair occur, so wound healing depends on reaching it. Option a is incorrect because N1 is only the doorway into sleep. It lasts a few minutes, accomplishes no restorative work, and a client roused from it often insists he never fell asleep. Option b is incorrect because the sleep spindles and K-complexes of N2 protect the sleep state and consolidate motor learning; although N2 fills nearly half the night, the anabolic repair work belongs elsewhere. Option d is incorrect because students reach for REM whenever a question sounds important. REM restores the mind through dreaming, memory consolidation and emotional processing, while the body's structural repair happens in deep sleep.

Correct Answer: Tolerance requiring upward dose titration

Tolerance is a physiological adaptation in which a given dose produces progressively less effect, so more drug is needed for the same relief. It is expected with sustained opioids and is managed by titration. Option a is incorrect because physical dependence shows itself only when the drug is stopped abruptly or an antagonist is given, producing a withdrawal syndrome. Nothing in this report describes withdrawal. Option b is incorrect because addiction is diagnosed from behavior, namely impaired control, craving, compulsive use and continued use despite harm. The stem rules those features out explicitly. Option c is incorrect because pseudoaddiction names drug seeking behavior that arises from undertreated pain and disappears once relief is adequate. This client is describing a change in drug response, not a behavior pattern.

Correct Answer: He was roused from his deepest sleep

Deep slow-wave sleep is concentrated in the first cycles of the night and is the hardest stage to leave. Being pulled out of it produces sleep inertia, with grogginess and slowed thinking that can linger. Option a is incorrect because dreaming sleep is back-loaded and the first such period does not arrive until roughly an hour and a half in. A sleeper woken from it usually orients quickly and recalls the dream. Option b is incorrect because delirium fluctuates over hours to days and carries inattention that persists between contacts. This client's fog clears on its own within a short time, which points to normal physiology. Option d is incorrect because the severity of the grogginess argues the opposite. Someone drifting only in the lightest stage wakes easily, often denying he slept, and does not spend the next half hour confused.

Correct Answer: The continuous background infusion of opioid

A basal infusion delivers opioid whether or not the client is awake, which destroys the built in protection that a drowsy client stops pressing. Routine basal rates are not recommended for opioid naive adults. Option a is incorrect because the lockout is a safety element, not a hazard. It is set near the drug's time to peak effect so doses cannot stack faster than the previous one can work. Option c is incorrect because an hourly ceiling exists precisely to bound the total dose over time. Removing or questioning it would widen the risk this client faces rather than narrow it. Option d is incorrect because a demand dose only reaches the client when the client presses the button. That requirement keeps the sedated client from receiving more drug, which is the whole point of the design.

Correct Answer: I will put a cloth under the ice pack.

A barrier between the pack and the skin prevents tissue injury, and cold is the right choice within the first day or two of an acute sprain. Applications run about fifteen to twenty minutes. Option b is incorrect because a sleeping client cannot feel the skin becoming numb or mottled and cannot remove the pack. Prolonged unmonitored cold causes blistering and tissue damage rather than added relief. Option c is incorrect because heat dilates vessels and increases blood flow, which worsens swelling and bleeding in a fresh injury. Heat has its place once the acute phase passes and stiffness becomes the problem. Option d is incorrect because applications are limited to roughly fifteen to twenty minutes with at least an hour between them. Two continuous hours of cold risks frostbite and reflex vasodilation that undoes the intended effect.

Correct Answer: Contact the provider about scheduled around-the-clock dosing

Continuous pain needs scheduled around-the-clock dosing, which holds a steady serum level and prevents the peaks that as-needed orders allow. Unrelieved pain on an inadequate regimen is a reportable finding that requires a provider order change. Option a is incorrect because the problem lies in the order, not in the client's timing. Even perfectly timed requests still leave gaps between doses, and coaching alone cannot convert an as-needed order into continuous coverage. Option b is incorrect because imagery is a useful addition once the drug regimen fits the pain pattern. Adding a cognitive technique to an order that leaves the client uncovered for hours postpones the change that is actually needed. Option c is incorrect because squeezing as-needed doses to their minimum interval still produces peaks and troughs and depends on someone being available each time. Scheduled dosing achieves better control at a lower total dose.

Correct Answer: About thirty minutes after the dose

Intravenous opioids reach peak effect within about fifteen to thirty minutes, so reassessment at that point shows whether the dose worked and catches sedation early. The commonly taught nursing standard is roughly thirty minutes after an intravenous dose. Option a is incorrect because the drug has not yet reached the receptors when the syringe empties. A score taken at that moment measures the pain the client already had and evaluates nothing about the intervention. Option b is incorrect because waiting two hours lets the peak pass unmeasured and also misses the window in which respiratory depression from an intravenous opioid is most likely. That interval belongs to no analgesic route. Option d is incorrect because shift-end timing is set by staffing convenience rather than by the drug. Evaluation intervals follow the onset and peak of the route used, and an unrelieved client would wait hours for a response.

Correct Answer: Review each tether and mobilize him today

Hospital-associated functional decline is largely caused by the hospital, and tethers are what keep a walking man in bed. Removing what is no longer needed and getting him up prevents delirium, pneumonia and deconditioning. Option b is incorrect because a support surface manages the consequence of immobility instead of ending it. Skin protection matters, yet a mattress accepts that he stays in bed, which is the problem the nurse must reverse. Option c is incorrect because he arrived walking without a device. Ordering equipment concedes a loss that has not happened yet, and muscle is lost daily on bed rest, so the window for preventing it is now. Option d is incorrect because therapy scheduled for next week arrives after the damage. Nursing does not need a consult to walk a patient to the bathroom, and delay in this population converts a short admission into a long one.