A nurse is caring for a client who received pain medication 1 hr ago and reports pain as 8 on a scale of 0 to 10. Which of the following actions should the nurse take first?
Document the finding in the client's medical record.
Re-evaluate the client's pain status in 1 hr.
Ask the client what has helped relieve their pain in the past.
Obtain a prescription for additional pain medication.
The Correct Answer is C
Rationale:
A. Documenting the pain is important but does not address the client’s immediate need for pain relief.
B. Waiting to re-evaluate in 1 hour delays intervention and does not prioritize the client’s current high pain level.
C. Asking the client what has helped relieve their pain in the past allows the nurse to assess effective interventions and tailor immediate pain management, making this the first action.
D. Obtaining a prescription may be necessary, but the nurse should first assess the client’s response to previous interventions and preferences before taking further steps.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Rationale:
A. Important for preventing future incidents, but not an immediate priority for the employee who is currently injured.
B. Critical to determine the chemical’s hazards and the correct emergency response, guiding immediate care.
C. Important for long-term safety and education but does not address the current injury.
D. Highest priority because the employee is experiencing burns and potential chemical injury; immediate treatment is necessary to prevent harm.
E. Essential to determine appropriate first aid, medical treatment, and reporting requirements; directly affects immediate care.
F. Preventive measure for the future; does not address the current exposure or injury.
Correct Answer is A
Explanation
Rationale:
A. Facial numbness after a thyroidectomy suggests hypocalcemia, likely due to parathyroid gland injury, and places the client at risk for laryngeal spasms and airway obstruction. This is the priority client.
B. Pain with voiding from acute pyelonephritis is important but not immediately life-threatening.
C. Teaching about insulin administration is necessary but not urgent compared to airway compromise.
D. Clear liquid stools before a colon resection are expected and indicate proper bowel preparation, not an urgent concern.
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