A nurse and an assistive personnel (AP) are caring for a client who requests a PRN pain medication. After the nurse administers the medication, which of the following tasks should the nurse assign to the AP?
Document the client's respiratory rate in 1 hr.
Monitor the client for an allergic reaction for 30 min.
Check the client's response to the medication in 1 hr.
Evaluate the client for therapeutic effects in 30 min.
The Correct Answer is A
A. Documenting the client's respiratory rate in 1 hour is within the scope of practice for an assistive personnel (AP) and does not require nursing judgment or assessment.
B. Monitoring the client for an allergic reaction for 30 minutes requires nursing judgment and assessment skills to recognize signs and symptoms of allergic reactions.
C. Checking the client's response to the medication in 1 hour requires nursing judgment and assessment skills to evaluate pain relief and any adverse effects.
D. Evaluating the client for therapeutic effects in 30 minutes requires nursing judgment and assessment skills to determine the effectiveness of the pain medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This is the correct answer. Reduction in blood pressure is a common therapeutic response to morphine administration. Morphine acts as a vasodilator, which can lead to decreased blood pressure.
B. Diaphoresis, or sweating, is not necessarily a therapeutic response to morphine. It may indicate other physiological responses or side effects.
C. Grimacing suggests pain or discomfort, which is not a therapeutic response but rather an indication that the pain relief from morphine may not be sufficient.
D. An elevated heart rate is not typically a therapeutic response to morphine and may indicate pain, anxiety, or other factors.
Correct Answer is C
Explanation
A. The ability to remove her own socks demonstrates motor skills development and independence, which are appropriate for an 18-month-old toddler.
B. Having a security blanket is a common comfort item for toddlers and is not typically a cause for concern.
C. The ability to say four words is below the expected language development milestone for an 18-month-old toddler, who should typically be saying 10 or more words by this age. Therefore, this finding should be reported to the provider for further evaluation.
D. Throwing a ball without falling demonstrates gross motor skills development, which is appropriate for an 18-month-old toddler.
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