A nurse is caring for a client who is requesting pain medication. Which of the following actions should the nurse perform first?
Administer the pain medication.
Ask the client the location of the pain.
Reposition the client.
Review the effects of the pain medications.
The Correct Answer is B
Choice A rationale
Administering pain medication without a complete assessment is unsafe and violates nursing standards. The nurse must first understand the nature, location, and severity of the pain to ensure the prescribed medication is appropriate. For example, if the pain is new or different, it could signify a medical emergency like a myocardial infarction or a surgical complication. Assessment is the first step of the nursing process and must be completed before any pharmacological intervention occurs.
Choice B rationale
Asking the client the location of the pain is the priority action because it is the first step in a thorough pain assessment. The nurse must determine the site, intensity using a 0 to 10 scale, quality, and duration of the pain. Collecting this objective and subjective data allows the nurse to identify the potential cause and select the most appropriate intervention. Effective pain management relies on accurate data collection to ensure patient safety and effective treatment outcomes.
Choice C rationale
Repositioning the client is a non-pharmacological comfort measure that can be very helpful, but it should not be the first action. While it may alleviate pressure or discomfort, the nurse must first assess the pain to ensure that repositioning is safe and appropriate. If the pain is due to a fracture or a wound dehiscence, moving the client without a proper assessment could cause further injury. Assessment always takes priority over implementing a comfort-based intervention.
Choice D rationale
Reviewing the effects of pain medications is an important part of the planning and evaluation phases of the nursing process, but it is not the first action when a client is currently experiencing pain. The nurse must prioritize the immediate needs of the client by assessing the current pain level and location first. Education and review of side effects can occur after the initial assessment is finished and as the nurse prepares to administer the treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Nutrition is a fundamental pillar of wound healing, as the body requires increased protein, vitamins A and C, and zinc to repair tissues. Food preferences are deeply influenced by cultural background, religious beliefs, and traditional practices. When creating a plan of care, the nurse must incorporate culturally acceptable foods to ensure the client adheres to the nutritional requirements needed for collagen synthesis and immune function. Ignoring these preferences can lead to malnutrition and significantly delayed wound closure.
Choice B rationale
While the time it takes to complete a dressing change is a logistical concern for the nurse, it is not primarily a cultural consideration for the plan of care. While some cultures have different perceptions of time, the clinical necessity of the procedure usually dictates the schedule. The focus of cultural care should be on the client's values and beliefs rather than the nurse's time management. Therefore, this option does not address the holistic cultural needs of the patient.
Choice C rationale
The cost of wound dressings is a socioeconomic factor rather than a cultural one. While financial status affects access to care and resources, it does not reflect the values, traditions, or social norms of a specific cultural group. A nurse should definitely consider the affordability of supplies to ensure compliance, but this falls under the category of social determinants of health rather than the cultural competence required to address the client's internal belief systems or diet.
Choice D rationale
The size of the home is an environmental or socioeconomic factor that may influence the logistics of care, such as space for supplies, but it is not a cultural consideration. Cultural considerations involve aspects like family structure, communication styles, and beliefs about health and illness. Knowing the home size does not provide insight into the patient's cultural identity or how their heritage might impact their recovery process, making it less relevant than nutritional preferences in care planning.
Correct Answer is ["15"]
Explanation
63 Step 1 is 15 mg ÷ 5 mg × 5 mL.
Step 2 is 3 × 5 mL.
Step 3 is 15 mL. The nurse should administer 15 mL.
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