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.
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Related Questions
Correct Answer is D
Explanation
Rationale:
A. A living will provides instructions for end-of-life care but does not authorize emergency surgical procedures.
B. The Good Samaritan Act protects healthcare providers who give emergency care outside a healthcare setting, not in-hospital surgical consent.
C. Joint liability refers to shared legal responsibility and is not related to consent for treatment.
D. Implied consent allows healthcare providers to perform emergency procedures when a client is unconscious or unable to give consent, and no legal representative is available, making it the correct legal guideline in this scenario.
Correct Answer is C
Explanation
Rationale:
A. A list of regularly prescribed medications is part of the written medical record and medication reconciliation process, but it is not the priority in a verbal transfer report.
B. The date of the last bowel movement is important for ongoing care but is not critical for immediate safety during transfer.
C. Level of consciousness provides essential information about the client’s current condition and potential safety needs, making it a priority in a verbal transfer report.
D. Laboratory results within the expected reference range do not require urgent communication since they do not indicate acute concerns.
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