The medical-surgical nurse is caring for a client with low back pain.
Item 1 of 1
- Flow Sheet
The nurse reviews the client's clinical data.
Which action should the nurse take based on the clinical data? Select all that apply.
The nurse reviews the client's clinical data.
Which action should the nurse take based on the clinical data? Select all that apply.
Statistics
Subject/Lesson
Subject
Adult Health
Lesson
Musculoskeletal
Client Need
Test Plan
Physiological Adaptation
Related Topic
Alterations in Body Systems
Item Type
Item Type
TakeAction
Explanation
Choice A is correct. The nurse received a prescription for ketorolac, which is a nonsteroidal anti-inflammatory drug (NSAID). It is appropriate for the nurse to administer this medication because the prescribed fentanyl is applied transdermally. Transdermal fentanyl peaks at 24 hours, and the client requiring an immediate release of pain medication, like ketorolac, is perfectly reasonable.
Choice B is correct. The nurse should remove the heating pad from the client's lower back. The client has a fentanyl patch applied to that area, and applying heat to the patch increases the circulation that results from the application of heat, which may result in increased absorption of medication, causing an overdose. Another alternative is for the nurse to reposition the prescribed fentanyl patch.
Choice C is incorrect. The nurse should not call the physician and question the prescribed ketorolac. There is no contraindication between ketorolac and fentanyl.
Choice D is incorrect. The client has low back pain, and Williams' position is one of the recommended positions for low back pain. The Williams position is typically more therapeutic for the client with low back pain. In this position, the client lies in the semi-Fowler position with a pillow under the knees to stay flexed. Twisting and bending at the waist is not recommended for a client with low back pain.
Choice E is incorrect. The nurse should not remove and discard the fentanyl patch because of its lack of efficacy. The fentanyl patch takes up to 24 hours to peak and should be removed 72 hours after it has been applied.
Additional Info
✓ Interventions for low back pain, including advising the client to avoid bending at the waist and twisting.
✓ Pharmacological pain management options include prescribed lidocaine patches (12 hours on; 12 hours off), non-steroidal anti-inflammatory drugs (NSAIDs), and, in rare cases, opioids.
✓ Nonpharmacological pain management options include warm compresses, transcutaneous electrical nerve stimulation (TENS), and physical therapy.
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