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 C
Explanation
A nurse reinforcing discharge teaching with the guardian of a client who is neutropenic should include the instruction to notify the provider if the child has a fever. A fever can be a sign of infection, which can be serious in a client who is neutropenic.
The other options are not correct.
A client who is neutropenic should avoid crowded places such as stores to reduce their risk of infection. The guardian should inspect the child's mouth daily, not weekly, for ulcers. A client who is neutropenic should avoid fresh fruits as they may carry bacteria that can cause infection.
Correct Answer is A
Explanation
Answer: A. Apply light pressure to the inner canthus just after instilling the eye drops.
Rationale:
A) Apply light pressure to the inner canthus just after instilling the eye drops.
Applying pressure to the inner canthus (the corner of the eye nearest the nose) helps occlude the nasolacrimal duct. This action reduces the systemic absorption of the medication by preventing it from draining into the nasal passages and subsequently into the systemic circulation, thus enhancing the local effect of the eye drops.
B) Wipe the eye from the inner to the outer canthus with a sterile saline-moistened cotton ball.
While this action may help remove excess medication or discharge, it does not minimize systemic absorption. Instead, wiping the eye could inadvertently spread the medication to other areas, increasing the chance of absorption rather than reducing it.
C) Administer the medication drops directly into the lower conjunctival sac of each eye.
While placing drops in the lower conjunctival sac is a standard practice for delivering ophthalmic medications, it does not directly influence systemic absorption. The main goal is to ensure adequate dosing in the eye, but systemic absorption can still occur if the drops drain into the nasolacrimal duct.
D) Wait 5 min after instillation before instilling the drops in the other eye.
Waiting between instillations is good practice to prevent dilution of the first dose and to allow for absorption. However, this action does not significantly impact systemic absorption. It focuses more on ensuring that the first dose is effective before administering a second dose.
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