A nurse is caring for a client who is postoperative following arthroscopy and reports a pain level of 6 on a scale of 0 to 10 after receiving ketorolac 1 hr ago.
Which of the following actions should the nurse take?
Tell the client they can have another dose of ketorolac in 3 hr.
Administer oxycodone 5 mg orally.
Give acetaminophen 650 mg rectally.
Document that the client is exhibiting drug-seeking behaviors.
The Correct Answer is B
Choice A rationale:
Ketorolac is a non-steroidal anti-inflammatory drug (NSAID) used for pain relief after surgery. However, it’s not typically administered every 3 hours. Overuse can lead to serious side effects.
Choice B rationale:
If the client’s pain level remains high after receiving ketorolac, administering an opioid medication like oxycodone may be appropriate.
Choice C rationale:
While acetaminophen can be used for pain relief, rectal administration is not typically the first choice for postoperative pain management.
Choice D rationale:
It’s inappropriate to label a patient as exhibiting drug-seeking behaviors simply because their reported pain level remains high after medication. Pain is subjective and should be addressed appropriately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Injecting the medication at least 5 cm (2 in) from the umbilicus is not a standard guideline for IM injections. The site of injection depends on factors such as the volume of medication and patient’s age and muscle mass.
Choice B rationale:
Using the Z-track technique to administer the medication is correct. This technique helps to seal the medication in muscle tissue, reducing leakage into subcutaneous tissue.
Choice C rationale:
Giving the medication without aspirating prior to injection is not recommended. Aspiration ensures that the needle is not in a blood vessel before injecting.
Choice D rationale:
Administering the medication with a 27-gauge '/,-inch needle may not be appropriate for an IM injection, especially for adults. A longer and larger gauge needle is typically used for IM injections.
Correct Answer is B
Explanation
Choice A rationale:
Asking the client to demonstrate dose delivery can be part of patient education and helps ensure that the client understands how to use the PCA device. This action does not require intervention.
Choice B rationale:
The nurse administering a PCA dose for the client requires intervention. PCA stands for “Patient-Controlled Analgesia,” meaning that only the patient should administer doses to themselves. This prevents overdosing and ensures that pain medication is administered according to the patient’s needs.
Choice C rationale:
Reassuring the client that the PCA device will not cause an overdose is appropriate because PCA devices are designed with safety measures to prevent overdosing.
Choice D rationale:
Monitoring for oversedation is an important part of care for a client using a PCA device. This action does not require intervention.
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