A client in the surgical recovery area asks the nurse to bring the largest possible dose of pain medication available. Which action should the nurse implement first?
Ask the client to rate the current level of pain using a pain scale.
Encourage the client to use diversional thoughts to manage pain.
Review the history for a past use of recreational drugs.
Determine when the last dose was administered.
The Correct Answer is A
Choice A rationale; When a client requests pain medication, the first action the nurse should take is to assess the client's current pain level. By using a pain scale, the nurse can determine the intensity of the pain and evaluate the need for pain medication appropriately. The pain scale allows the client to express their pain on a standardized scale, helping the nurse to understand the severity of the pain and the most appropriate pain management intervention.
Choice B rationale: While diversional thoughts and non-pharmacological pain management techniques can be useful, the priority is to first assess the pain level and address the client's immediate needs for pain relief.
Choice C rationale: While it's important to consider the client's history of drug use, it is not the first action to take when a client requests pain medication. Assessing the pain level and providing appropriate pain relief should be the initial priority.
Choice D rationale: While it's essential to know the last dose of pain medication the client received, it is not the first action to take when the client is requesting pain medication. Assessing the current pain level and addressing the client's immediate needs should be the first step. The information about the last dose will be relevant for deciding when the next dose can be given.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: This option is not appropriate as increasing saturated fat intake would exacerbate the oily stool and flatus symptoms caused by orlistat. Orlistat is specifically designed to reduce fat absorption, and increasing fat intake would be counterproductive and may worsen the side effects.
Choice B rationale: Asking a client to describe their dietary intake history is a standard practice in nutritional assessment. It provides a baseline for understanding current eating habits and identifying areas for improvement.
Choice C rationale: Advising a client to stop taking medication should only be done by a qualified healthcare provider who has full knowledge of the client's health history and current medications.
Choice D rationale: While obtaining a stool specimen for evaluation might be relevant in some situations, it is not the priority in this case. The oily stools and flatus are most likely related to the side effects of orlistat and do not typically require stool testing for confirmation. The more immediate action would be to address the symptoms by advising the client to stop taking the medication and contact her healthcare provider for further guidance.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"}}
Explanation
Choice A rationale: Indicated. This is important for a client with type 1 diabetes, as counting carbohydrates helps in calculating the appropriate insulin dose and maintaining glycemic control.
Choice B rationale: Non-essential. The client is already admitted to the surgical floor and does not require restarting the IV fluids unless there is a specific medical indication.
Choice C rationale: Contraindicated. Insulin doses should be prescribed by a healthcare provider based on the patient's blood glucose levels and individual insulin requirements. The nurse should follow the prescribed insulin orders and not administer insulin without an order.
Choice D rationale: Indicated. Insulin glargine is a long-acting basal insulin used to provide a steady background insulin level throughout the day. The nurse should administer the prescribed insulin glargine dose as ordered.
Choice E rationale: Contraindicated. Insulin lispro is a rapid-acting insulin, and insulin glargine is a long-acting insulin. Mixing different types of insulin in one syringe can alter their pharmacokinetics and lead to inconsistent blood glucose control. Insulin lispro and insulin glargine should be administered separately.
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