A nurse is collecting data from a client who is postoperative and received hydromorphone 4 mg PO 15 min ago. The client tells the nurse, "My pain level is still 8 on a 0 to 10 scale." Which of the following actions should the nurse take first?
Contact the provider to prescribe more pain medication for the client.
Teach the client relaxation techniques for the treatment of acute pain.
Document the client's reaction to the administration of medication.
Reevaluate the client's response to the medication in 30 min.
The Correct Answer is D
The first action the nurse should take is to reevaluate the client's response to the medication in 30 min. Hydromorphone has an onset of action of 15 to 30 minutes when taken orally ¹. Therefore, it may take some time for the medication to reach its full effect.
Option a is incorrect because it may not be necessary to contact the provider for more pain medication until after reevaluating the client's response to the medication.
Option b is incorrect because teaching relaxation techniques may not provide immediate relief for acute pain.
Option c is incorrect because documenting the client's reaction to the administration of medication should be done after reevaluating their response to the medication.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should recommend that the client who has diminished breath sounds and paradoxical chest movement receive care first. This client is likely experiencing a tension pneumothorax, which is a life-threatening condition that requires immediate intervention.
Option a is incorrect because a client who has a head injury and whose pupils are fixed and dilated may have experienced brain death and may not be able to be resuscitated.
Option b is incorrect because a dislocated shoulder, while painful, is not immediately life-threatening. Option c is incorrect because a scalp laceration with intermittent bleeding can be managed with pressure and is not immediately life-threatening.
Correct Answer is A
Explanation
Immunocompromised individuals have a weakened immune system, which makes them more susceptible to infections. Soiled linens, when placed on the floor, can potentially harbor pathogens and become a source of contamination. It is essential to handle soiled linens properly by placing them in designated containers or bags to prevent the spread of infectious agents.
Uncapped sharps put in a puncture-resistant container: This is the correct practice for disposing of sharps, such as needles or lancets. Uncapped sharps should always be placed in puncture-resistant containers to prevent accidental injuries and potential transmission of infections.
Dampened cloths used for dusting the area: Dampened cloths for dusting can help minimize the dispersal of dust and allergens, but it does not necessarily pose a significant risk of infection.
However, it is important to ensure that the dampened cloths are properly cleaned and sanitized to prevent the growth and spread of microorganisms.
Waste containers lined with single bags: Waste containers lined with single bags are a common practice for proper waste management and disposal. While it is important to maintain good waste management practices to prevent the spread of infections, the use of single bags alone does not significantly affect the risk of infection for immunocompromised clients.
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