The nurse receives orders for an opiate pain medication for a client with severe pain. What other order does the nurse anticipate getting?
Fluid restriction by mouth
A low salt diet
A chest x-ray
Stool softener medication
Antidiarrheal medication
The Correct Answer is D
A. Fluid restriction by mouth is not typically necessary with opioid administration unless other health conditions require it.
B. A low salt diet is unrelated to opioid administration unless there are concurrent health issues like hypertension or fluid retention.
C. A chest x-ray is not indicated solely due to opioid use.
D. Stool softener medication is commonly prescribed alongside opioid medications because opioids frequently cause constipation due to reduced gastrointestinal motility.
E. Antidiarrheal medication is not needed, as opioids are more likely to cause constipation rather than diarrhea.
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Correct Answer is A
Explanation
A. Auscultate for any cardiac murmurs is correct, as a thrill often indicates turbulent blood flow, which may correlate with murmurs that can be heard upon auscultation.
B. Comparing apical and radial pulse rates is useful in assessing pulse deficits but does not directly address the cause of the thrill.
C. Palpating the quality of the peripheral pulses does not provide specific information about the thrill's origin.
D. Finding the point of maximal impulse is a useful cardiac assessment but does not directly explain the cause of the thrill.
E. Checking capillary refill time assesses peripheral perfusion but does not relate to the thrill's cause.
Correct Answer is B
Explanation
A. 3+ edema indicates moderate pitting (indentation depth of 5-7 mm and lasting 10-20 seconds).
B. 1+ edema is classified as slight pitting (indentation depth less than 2 mm that disappears rapidly, typically in less than 10 seconds), making this the correct documentation.
C. 2+ edema indicates moderate pitting (indentation depth of 3-4 mm that lasts up to 15 seconds).
D. +0 indicates no edema present at all.
E. 4+ edema indicates severe pitting (indentation depth of greater than 8 mm and lasting more than 20 seconds).