A client is complaining of severe pain after being medicated one hour ago with hydrocodone with acetaminophen one tablet orally. Which intervention should the nurse implement next?

Tell the client the medication needs more time to work.

Reassess the client and the level of pain.

Ask the unlicensed assistive personnel (UAP) to offer a backrub to the client.

Encourage the client to focus on taking deep breaths.

Answer and Explanation

The Correct Answer is B

A. Telling the client the medication needs more time: While true for some medications, it's important to assess the severity of the pain to determine if further action is needed.

B. Reassessing the client's pain: This is the most crucial step. Reassessment helps determine the effectiveness of the medication and identify any potential issues.

C. Asking UAP to offer a backrub: While comfort measures can be helpful, delegation to an UAP should only occur after a nurse assessment and with clear instructions. In this case, pain management is the priority.

D. Encouraging deep breaths: Distraction techniques can be a complementary approach, but reassessing the pain level is the most urgent step.

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Correct Answer is C

Explanation

A. Diminished appetite: While this can be a symptom of various conditions, it's not a direct indicator for a bone density screening.

B. Lower body mass index (BMI): A lower BMI can increase the risk of osteoporosis, but it's not a definitive sign requiring immediate bone density screening.

C. Decreased height: Losing height as an adult can be a sign of vertebral fractures caused by osteoporosis. This is a significant finding that warrants a bone density screening to assess bone mineral density.

D. 15-pound weight loss: Sudden or unexplained weight loss can be a concern, but it doesn't directly suggest the need for a bone density test unless accompanied by other risk factors.

A. Blue tinge in the nail beds. B. Ashen grey tone to lips. C. Ashy yellow appearance of skin. D. Reddish purple colored palms.

Correct Answer is A

Explanation

A. Blue tinge in the nail beds: This finding is indicative of cyanosis. When oxygen levels in the blood are low, the skin and mucous membranes may appear bluish due to inadequate oxygenation. The nail beds are a common area to observe this bluish discoloration.

B. Ashen grey tone to lips: While this can be concerning, it is not a classic sign of cyanosis. Ashen grey lips may be associated with other conditions, such as shock or poor perfusion, but they do not specifically indicate cyanosis.

C. Ashy yellow appearance of skin: This finding is not related to cyanosis. An ashy yellow appearance may be seen in conditions like liver disease or jaundice, but it does not reflect oxygenation status.

D. Reddish purple colored palms: Again, this is not a sign of cyanosis. Reddish or purple palms may be seen in various conditions, but they do not specifically point to inadequate oxygen levels.

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A client is complaining of severe pain after being medicated one hour ago with hydrocodone with acetaminophen one tablet orally. Which intervention should the nurse implement next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is A

Explanation

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