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.

Answer and Explanation

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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Correct Answer is D

Explanation

The presence of alcohol on a nurse's breath raises concerns regarding impairment and the potential for compromised patient safety. It is crucial to prioritize patient safety and prevent any potential harm. Removing the nurse from the client care area ensures that immediate patient safety is addressed and minimizes the risk of any adverse events.

Call the supervisor to ask for another nurse: While involving the supervisor is important, it should not be the first action taken in this situation. The immediate priority is to address patient safety by removing the nurse from the client care area.

Assign clients to the remaining staff: Assigning clients to the remaining staff should not be the first action taken because it may compromise patient safety if the nurse in question is impaired. It is important to ensure that the nurse is removed from the client care area before reassigning the clients to other staff members.

Document objective findings about the situation: Documenting the objective findings about the situation is important for accurate record-keeping and reporting. However, it should not be the first action taken when immediate patient safety is at stake. Removing the nurse from the client care area is the priority.

A. Provide the client with 1 week's supply of insulin syringes B. Arrange for a home health nurse to visit the client daily C. Notify the family of the client's health status D. Refer the client to a diabetic support group.

Correct Answer is B

No explanation

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse in a long-term care facility notices the smell of alcohol on a nurse's breath. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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Correct Answer is B

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