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. Teach the client to rotate the meal plate to visualize all the food on the plate: While this intervention may be helpful for other reasons, it does not directly address the client’s difficulty walking in a straight line.

B. Instruct the client to lift the left extremities with the right hand when transferring: This intervention helps with weight-bearing and balance during transfers. It compensates for the left hemiplegia and promotes stability.

C. Implement precautions when the client is judging distances during transfers: This is crucial. Clients with hemiplegia may have impaired spatial awareness and difficulty judging distances. Strategies like using a gait belt, providing cues, or ensuring a clear path can help prevent falls. Implementing precautions during transfers helps prevent falls.

D. Encourage the client to touch, wash, look at, and dress the affected side first: While this approach promotes independence, it does not directly address the client’s gait instability.

A. Assess for the use of illicit drugs. B. Obtain a smoking history first. C. Evaluate vital signs and laboratory findings. D. Ask the parents to leave the room.

Correct Answer is D

Explanation

A. Assess for the use of illicit drugs. While assessing illicit drug use is important, it may not be the most crucial intervention during the initial health history-taking process.

B. Obtain a smoking history first. While obtaining a smoking history is important, it may not take precedence over other aspects of the health history, especially if there are more pressing concerns.

C. Evaluate vital signs and laboratory findings. While vital signs and laboratory findings are important components of the assessment, they are typically obtained after the health history has been completed.

D. Ask the parents to leave the room. Ensuring privacy and confidentiality is crucial during adolescent health assessments to encourage open communication and address sensitive issues. Asking the parents to leave the room allows the adolescent to speak freely about their health concerns without fear of judgment or disclosure to their parents.

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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

While assisting a client to ambulate who has left hemiplegia due to a stroke, the nurse notices that the client is having difficulty walking in a straight line. Based on this assessment finding, it is most important to include which intervention in this client's plan of care?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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