A patient is receiving a continuous infusion of morphine via an epidural catheter following major abdominal surgery. Which actions should the nurse include in the plan of care (select all that apply)?

Correct Answer: B

Rationale: In this scenario, the correct action to include in the plan of care is to assess the patient's pain relief frequently (Option B). Rationale for B: Assessing the patient's pain relief frequently is crucial when a patient is receiving a continuous infusion of morphine via an epidural catheter. This is important to ensure that the pain is adequately controlled and to monitor for any signs of inadequate pain relief or potential complications related to the medication. Rationale for A, C, and D: Option A: Labeling the catheter as an epidural access is important but is not directly related to the immediate care of the patient or ensuring proper pain management. Option C: Using sterile technique when caring for the catheter is a standard practice in any medical procedure but does not directly impact the assessment of pain relief in this context. Option D: Monitoring the patient's level of consciousness (LOC) is important in general patient care but is not as directly related to assessing the effectiveness of pain relief in this specific situation. Educational Context: Understanding the rationale behind the correct action emphasizes the importance of pain assessment in patients receiving opioid medications like morphine. Regular pain assessment is essential for effective pain management and patient comfort, especially in the postoperative period. It also highlights the need for nurses to prioritize pain management interventions to ensure optimal patient outcomes.

Correct Answer: A

Rationale: In the context of caring for a dying patient and their family, managing anxiety is a crucial aspect of holistic care. Addressing anxiety can help alleviate distress, improve communication, and enhance overall well-being. The correct answer, option A, is essential because anxiety is a common response to end-of-life situations and can significantly impact the patient and family's experience. Fear of pain, option B, is also a valid concern, but it is more specific and may not be as universally present as anxiety. The dying process, option C, is a broad concept that encompasses various physical, emotional, and spiritual aspects, which can be challenging to manage comprehensively. Anger toward the nurse, option D, is not an appropriate focus when providing end-of-life care, as it can hinder trust and collaboration between the healthcare team and the patient/family. Educationally, understanding the psychosocial and physical care needs of dying patients and their families is crucial for nurses. By prioritizing the management of anxiety, nurses can create a supportive environment that promotes comfort, dignity, and emotional well-being during this sensitive time.

Correct Answer: D

Rationale: Rationale: The correct answer is D) This test determines how well your tissues are oxygenated. Arterial blood gas (ABG) tests are crucial in assessing a patient's oxygenation status. They provide information on the levels of oxygen and carbon dioxide in the blood, as well as the blood's acidity (pH) and bicarbonate levels. In Joan's case, these tests are likely being done to monitor her oxygen levels, especially if she has a condition affecting her respiratory system or if she is on oxygen therapy. Option A) This test determines if your liver and kidneys are functioning properly is incorrect because ABG tests do not assess liver and kidney function. Tests like liver function tests and renal function tests are specifically designed for that purpose. Option B) This test determines if you have sufficient WBC to fight infection is incorrect because ABG tests do not measure white blood cell levels. A complete blood count (CBC) is used to evaluate white blood cell count. Option C) This test determines if you are hyperglycemic, which is a side effect of your medication is incorrect because ABG tests do not measure blood glucose levels. Blood glucose tests like fasting blood sugar or HbA1c are used to monitor glucose levels in the blood. In an educational context, understanding the purpose of different diagnostic tests is essential for providing quality patient care. Educating patients like Joan about the reasons behind specific tests can help them feel more involved in their care and improve their overall health literacy.

Correct Answer: B

Rationale: In this scenario, Bob experiencing chest pain that occurs with exertion and is relieved by rest indicates he is likely experiencing stable angina (Option B). Stable angina is chest pain or discomfort that typically occurs with physical activity or stress due to reduced blood flow to the heart muscle. It is a predictable and manageable condition that is often triggered by exertion and relieved by rest or medications like nitroglycerin. Option A, indigestion, is incorrect because the pain in stable angina is typically exertional and related to the heart, not the digestive system. Option C, unstable angina, is characterized by chest pain at rest or with minimal exertion and is considered a medical emergency requiring immediate attention. Option D, Prinzmetal's angina, is caused by coronary artery spasm rather than blockages from plaque buildup, and typically occurs at rest rather than with exertion. Educationally, understanding the differences between types of angina is crucial for healthcare providers to accurately assess and manage patients with chest pain. Recognizing the characteristics of stable angina helps in differentiating it from other types of angina and conditions with similar symptoms, guiding appropriate interventions and improving patient outcomes.

Correct Answer: A

Rationale: In the context of postoperative care, monitoring for atelectasis in patients returning from the operating room is crucial because of the increased risk associated with immobility, anesthesia, and inadequate deep breathing. Option A is correct because immobility can lead to decreased lung expansion and secretion clearance, anesthesia can depress respiratory drive and impair cough reflex, and lack of deep breathing can result in collapsed alveoli, all contributing to the development of atelectasis. Option B is incorrect because while postoperative patients are indeed at risk for various complications, not all of them are at risk for infection specifically. Option C is incorrect because receiving too much oxygen during surgery is not a common cause of atelectasis; in fact, oxygen therapy is often used to prevent atelectasis. Option D is also incorrect because postoperative patients typically receive adequate oxygenation during surgery, and inadequate oxygen delivery is not a primary cause of atelectasis in this context. Educationally, understanding the pathophysiology of atelectasis postoperatively is crucial for nurses and healthcare providers to implement appropriate preventive measures such as early mobilization, incentive spirometry, and respiratory exercises to reduce the risk of lung collapse and promote optimal postoperative recovery. Monitoring for atelectasis allows for early detection and prompt intervention, ultimately improving patient outcomes and reducing the incidence of respiratory complications following surgery.