A nurse administered 400 mg of ibuprofen to a client 2 hr ago to treat pain following a biopsy. The client is crying and states. "It really still hurts a lot. Which of the following actions should the nurse take?
Ask the client to rate their pain on a scale of 0 to 10.
Request a prescription for on opioid pain medication for the client
Report this client finding to the provider.
Administer an additional dose of ibuprofen to the client.
The Correct Answer is A
A. Ask the client to rate their pain on a scale of 0 to 10: Pain assessment is the first step in managing pain effectively. Using a standardized pain scale helps determine the severity, effectiveness of the previous dose, and guides subsequent interventions or medication adjustments.
B. Request a prescription for an opioid pain medication for the client: While opioids may be appropriate for breakthrough pain, the nurse must first assess the current pain level and response to prior medication before requesting additional prescriptions. Immediate escalation is premature without assessment.
C. Report this client finding to the provider: Reporting is important if pain persists despite interventions, but initial assessment and documentation of pain severity should precede notifying the provider to provide accurate information.
D. Administer an additional dose of ibuprofen to the client: Administering another dose without verifying timing, maximum daily dosage, or assessing pain response could risk overdose or toxicity. Pain assessment must guide safe medication administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. "This medication can cause nausea and drowsiness.": Gastrointestinal upset and central nervous system effects such as drowsiness are common early adverse effects of lithium therapy. Clients should be informed so they can recognize mild side effects versus signs of toxicity.
B. "You will be placed on a low-sodium diet while taking this medication.": Lithium requires a consistent, not low, sodium intake. Low sodium can increase lithium reabsorption in the kidneys, raising the risk of toxicity. Emphasizing a consistent dietary sodium intake is important rather than restricting sodium.
C. "Blurred vision is an expected adverse effect of this medication.": Blurred vision is not an expected side effect of lithium and may indicate toxicity or another ocular issue. Clients should report changes in vision promptly rather than consider them routine.
D. "This medication can cause weight gain.": Weight gain is a known side effect of lithium therapy due to fluid retention and metabolic changes. Clients and caregivers should be aware to monitor weight and maintain healthy lifestyle practices.
E. "It will take at least a week before this medication reaches a therapeutic level.": Lithium requires several days to reach a therapeutic blood level, and effects on mood stabilization are gradual. Educating the client about delayed onset helps set realistic expectations and encourages adherence.
Correct Answer is D
Explanation
A. Dietitian: While nutrition can play a role in overall health and inflammation management, a dietitian referral is not the primary intervention for rheumatoid arthritis. Dietary counseling may be considered adjunctively but is not central to preserving joint function.
B. Case manager: A case manager helps coordinate care and resources, which may be helpful for complex cases, but referral is not specifically targeted to managing the functional impairments associated with rheumatoid arthritis.
C. Podiatrist: A podiatrist is consulted if the client develops foot or ankle complications. Routine referral is not indicated unless specific joint issues are present in the lower extremities.
D. Physical therapist: Physical therapy is essential in rheumatoid arthritis care to maintain joint mobility, reduce pain, and prevent deformities. A physical therapist develops individualized exercise programs, educates on joint protection, and supports functional independence, making this referral highly appropriate.
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