A client with lung cancer and bone metastasis is grimacing and states, "I am a little uncomfortable. May I please have something for pain? Which nursing intervention should be taken before administering the pain medication?
Assess the client's pain level using a pain rating scale.
Provide distraction techniques, such as music or guided imagery, to help alleviate the discomfort.
Administer the pain medication immediately to provide relief.
Encourage the client to practice relaxation techniques to manage the pain.
The Correct Answer is A
Rationale:
A. Before administering pain medication, the nurse must assess the client’s pain to determine its intensity, location, and characteristics. Using a standardized pain rating scale ensures accurate dosing, helps evaluate the effectiveness of interventions, and prevents under- or over-medication. Pain assessment is considered the first and essential step in pain management.
B. Nonpharmacologic methods like distraction can help manage pain, but they do not replace the need for a proper pain assessment before administering medication. These techniques are complementary interventions, not a substitute for assessment.
C. Administering medication without assessing the pain level is unsafe. It can lead to inappropriate dosing, ineffective pain relief, or adverse effects. Proper assessment guides safe and effective pain management.
D. Relaxation techniques may be helpful as adjunctive pain management, but they should not precede pain assessment. Accurate assessment is necessary to determine if pharmacologic intervention is needed and at what dose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Hot flashes are a common, expected side effect of tamoxifen and are usually not dangerous. Stopping the medication without consulting the provider could reduce the effectiveness of breast cancer treatment.
B. Taking tamoxifen with food may help reduce minor gastrointestinal discomfort, but this is not the priority safety concern. Gastrointestinal upset is generally mild and not life-threatening.
C. Tamoxifen increases the risk of endometrial cancer and thromboembolic events. Unusual vaginal bleeding, spotting, or discharge can be an early sign of endometrial cancer or other serious complications. Prompt reporting allows early evaluation and intervention, making this instruction a priority for patient safety.
D. Grapefruit can interact with some medications metabolized by CYP3A4, but it is not a major concern with tamoxifen. While general dietary precautions can be discussed, early detection of serious adverse effects takes precedence.
Correct Answer is D
Explanation
Rationale:
A. Superficial spreading melanoma usually presents as a variegated lesion with shades of brown, tan, or black, often with irregular borders and asymmetry. A purplish hue is not typical of this type of melanoma; lesions with purple tones may indicate vascular lesions (like hemangiomas) or rare cancers such as Kaposi sarcoma.
B. Early superficial spreading melanoma is typically painless. Pain is not a reliable indicator of early melanoma and usually only occurs if the lesion becomes ulcerated, infected, or grows deeply into the skin layers, which is more characteristic of advanced disease.
C. Melanoma is a malignant lesion, not an infection, so it does not normally produce pus. Purulent drainage would suggest a bacterial infection, abscess, or skin ulcer rather than a cancerous lesion.
D. Pruritus, or itching, is an expected finding in superficial spreading melanoma. Patients may notice mild irritation or tingling at the site of the lesion, often before any other changes are apparent. This symptom, combined with changes in size, color, shape, or the appearance of new moles, should alert the nurse to the possibility of melanoma and the need for further evaluation.
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