HESI RN
HESI RN Fundamentals Questions
Extract:
History and Physical
The client is a 56-year-old woman who had an anteroposterior spinal fusion 2 days ago. She tolerated the procedure well and has been progressively increasing her walking distance.
Nurse’s Notes
12:00
Vital Signs:
• Heart rate: 98 beats/minute
• Pain rating: 5 on a 0 to 10 pain scale
Morphine 2.5 mg given IV push (IVP). The client ambulated twice with physical therapy.
13:00
Vital Signs:
• Heart rate: 78 beats/minute
• Pain rating: 3 on a 0 to 10 pain scale
Ibuprofen 800 mg given PO. The client is resting in bed.
14:00
Vital Signs:
• Heart rate: 118 beats/minute
• Pain rating: 8 on a 0 to 10 pain scale
Orders
• Up ad lib
• Regular diet
• Ibuprofen 800 mg PO every 8 hours for pain rated at 2 to 4 on a 0 to 10 pain scale
• Morphine 2.5 mg IV push every 4 hours for pain greater than 4 on a 0 to 10 pain scale
Question 1 of 5
Based on the trending heart rate and pain score, what should the nurse do? Select all that apply.
Correct Answer: A,C,E,F
Rationale:
Choice A reason:
The increase in heart rate from 78 to 118 beats per minute, along with the increase in pain rating from 3 to 8, suggests that the client may be experiencing pain from a source other than the surgical site. It is important to assess for other potential sources of pain to ensure comprehensive pain management.
Choice B reason:
Changing to a behavioral pain scale is not indicated in this scenario. The numerical pain scale is a standard and effective method for assessing pain levels, and there is no indication that the client has difficulty communicating her pain using this scale.
Choice C reason:
Given that the client's pain rating increased to 8, which is above the threshold of 4 on the pain scale, administering a dose of 2.5 mg of morphine as per the orders is appropriate to manage her pain.
Choice D reason:
Referring to social work for drug-seeking behavior is not supported by the information provided. The client's increased pain rating and heart rate suggest a legitimate need for pain management rather than drug-seeking behavior.
Choice E reason:
Bringing an opioid reversal agent to the bedside is not indicated unless there is a concern for opioid overdose, which is not suggested by the information provided.
Choice F reason:
While guided imagery can be a helpful adjunct for pain management, it is not the primary intervention needed at this time given the client's significant increase in pain and heart rate.
Choice G reason:
Consulting with the surgeon about the client's increased pain level is important to rule out any complications from the surgery and to discuss further pain management strategies.
Choice H reason:
Assisting the client to walk around the room may help in pain management and is part of the postoperative care plan to increase walking distance. However, it should be done cautiously considering the client's current pain level.
Extract:
Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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