A client is receiving pain medications as needed. Which of the following interventions are important following the administration of pain medication? (Select all that apply)
Reassess pain score.
Assess the surgical site.
Reassess vital signs.
Assess for bowel sounds.
Assess level of consciousness.
Correct Answer : A,C,E
Choice A reason: Reassessing the pain score is critical to evaluate the medication’s effectiveness. Pain is subjective, and reassessment using a numerical scale (e.g., 0-10) quantifies relief, guiding further dosing or alternative interventions. This ensures adequate pain control, optimizing patient comfort and recovery.
Choice B reason: Assessing the surgical site is important for monitoring complications like infection or bleeding but is not directly related to pain medication administration. Pain relief does not typically alter surgical site appearance, making this assessment less immediate compared to pain or systemic effects of analgesics.
Choice C reason: Reassessing vital signs is essential as pain medications, especially opioids, can cause respiratory depression, hypotension, or bradycardia. Monitoring heart rate, blood pressure, and respiratory rate ensures patient safety, detecting adverse effects early to prevent complications like hypoxia or cardiovascular instability.
Choice D reason: Assessing bowel sounds is relevant for long-term opioid use due to risks of constipation, but it’s not an immediate post-administration priority. Pain medications’ acute effects primarily involve pain relief and systemic responses, not gastrointestinal motility, making this less critical in the immediate post-dose period.
Choice E reason: Assessing level of consciousness is crucial as pain medications, particularly opioids, can cause sedation or altered mental status. Monitoring alertness ensures patient safety, detecting overdose or adverse reactions early, which could lead to respiratory depression or other life-threatening complications if unaddressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Visceral pain arises from internal organs, like the stomach, and is often described as burning, diffuse, or radiating, as the patient reports. It results from organ distension, inflammation, or ischemia, matching the described gastric, circular pain pattern.
Choice B reason: Chronic pain persists beyond 3 months and is not defined by location or quality. The patient’s 3-day pain is acute, not chronic, and the description aligns with visceral pain, not a chronic condition.
Choice C reason: Idiopathic pain has no identifiable cause. The patient’s pain, localized to the stomach with a burning, radiating quality, suggests a visceral origin (e.g., gastritis), making idiopathic an incorrect classification.
Choice D reason: Superficial pain originates from skin or mucous membranes, described as sharp or localized. The patient’s deep, burning, and radiating gastric pain is characteristic of visceral pain, not superficial pain.
Correct Answer is A
Explanation
Choice A reason: An ascending colon ostomy produces very liquid stool because this proximal colon segment primarily absorbs water and electrolytes. Minimal water reabsorption occurs here, resulting in high fluid content in the stool, unlike more distal colon segments where stool becomes more formed.
Choice B reason: A descending colon ostomy produces semi-formed stool. This segment further absorbs water, concentrating fecal matter compared to the ascending colon. The stool is less liquid, reflecting increased water reabsorption, making it less characteristic of very liquid output.
Choice C reason: A sigmoid colon ostomy produces formed stool. The sigmoid colon stores and compacts feces, with significant water reabsorption, resulting in solid, less frequent output. This contrasts with the liquid stool expected from more proximal ostomies like the ascending colon.
Choice D reason: A transverse colon ostomy produces semi-liquid to semi-formed stool. Positioned between the ascending and descending colon, it absorbs more water than the ascending colon but less than the sigmoid, resulting in thicker output, not very liquid stool.
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