A client is requesting medicine for pain 30 minutes after receiving morphine sulfate 5 mg intravenously. Which intervention should the nurse implement next?
Ask the UAP to offer a backrub to the client.
Reassess the client and the level of pain.
Tell the client the medication needs more time to work.
Encourage the client to focus on taking deep breaths.
The Correct Answer is B
A. Asking a UAP to offer a backrub is not appropriate if the pain assessment indicates that the current pain management strategy is insufficient. The nurse needs to reassess the pain to determine the effectiveness of the medication and whether additional interventions are needed.
B. Reassessing the client and the level of pain is essential to evaluate the effectiveness of the morphine sulfate administered and to guide further pain management decisions. This step is crucial for understanding the client's current pain status and determining the next steps in pain management.
C. Telling the client that the medication needs more time to work does not address the client's immediate concern or pain relief. Reassessing pain and potentially adjusting the treatment plan is more appropriate.
D. Encouraging deep breathing may help with pain management but does not address the need for further assessment of the pain level or potential adjustment in medication. Reassessing pain is the priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Acknowledging that this is a difficult time for the mother is empathetic and supportive. It provides an opportunity for the mother to express her feelings and concerns without placing blame, which can be helpful in managing emotional distress.
B. While reassuring the mother that she did nothing wrong is important, it does not fully address her emotional needs or allow her to express her feelings. It may be perceived as dismissive if not accompanied by empathy.
C. Reassuring the mother about the outcome of surgery is important, but it does not address the emotional impact of her feelings of guilt or responsibility.
D. Asking why the mother thinks it is her fault may not be as supportive or helpful as providing empathy and reassurance. It could potentially lead to further distress rather than addressing the emotional support she needs.
Correct Answer is B
Explanation
A. While applying a barrier ointment is important for preventing further skin breakdown, it does not address the immediate need to assess the severity of existing damage.
B. Determining the size and depth of skin breakdown is crucial for assessing the severity of the pressure injury and planning appropriate treatment. Accurate assessment helps in selecting the right interventions and monitoring the progression of the wound.
C. Completing a functional assessment of the client's self-care abilities is important for overall care planning but should follow the initial assessment of the skin breakdown to ensure immediate needs are addressed.
D. Establishing a toileting schedule is a preventive measure for future incontinence but does not address the current skin breakdown that needs immediate assessment and treatment.
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