A nurse is evaluating a patient's response to pain medication after surgery. The patient reports that his pain level is 8 out of 10 on a numeric rating scale, despite receiving morphine 10 mg intravenously 30 minutes ago. What should the nurse do first?

Assess the patient's vital signs and oxygen saturation.

Notify the physician and request a different medication.

Reassess the patient's pain level in another 15 minutes.

Provide nonpharmacological interventions such as massage or distraction.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Assessing the patient's vital signs and oxygen saturation is the first step in evaluating the patient's response to pain medication. This is because vital signs and oxygen saturation can indicate the severity of pain, the effectiveness of the medication, and the presence of any adverse effects such as respiratory depression or hypotension. Assessing vital signs and oxygen saturation is also consistent with the nursing process of assessment, which guides the nurse's subsequent actions.

Choice B reason:

Notifying the physician and requesting a different medication is not the first action that the nurse should take. The nurse should first assess the patient's condition and determine the cause of inadequate pain relief. The physician may not be available or may not agree to change the medication without further information. Changing the medication may also not be necessary or appropriate, depending on the patient's pain level, type of pain, allergies, contraindications, and preferences.

Choice C reason:

Reassessing the patient's pain level in another 15 minutes is not the first action that the nurse should take. The patient is reporting a high level of pain (8 out of 10) despite receiving morphine 10 mg intravenously 30 minutes ago. This indicates that the patient is experiencing breakthrough pain, which is a sudden increase in pain intensity that occurs despite adequate analgesia. Breakthrough pain requires immediate attention and intervention, not delayed reassessment.

Choice D reason:

Providing nonpharmacological interventions such as massage or distraction is not the first action that the nurse should take. Nonpharmacological interventions are complementary methods that can enhance the effect of pharmacological interventions, but they are not sufficient to treat severe acute pain by themselves. The nurse should first assess the patient's condition and administer additional analgesia if indicated and prescribed before implementing nonpharmacological interventions.

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Correct Answer is B

Explanation

Choice A reason:

Independent nursing interventions are actions that nurses can perform by themselves, without any management from a doctor or another discipline. For example, checking vital signs, repositioning a patient, or providing patient education are independent nursing interventions. These interventions do not require a health care provider's order.

Choice B reason:

Dependent nursing interventions are actions that nurses perform under the direction of a physician or as part of a care plan. For example, administering medications, performing diagnostic tests, or inserting an intravenous line are dependent nursing interventions. These interventions require a health care provider's order.

Choice C reason:

Collaborative nursing interventions are actions that nurses perform in coordination with other health care professionals, such as physicians, pharmacists, dietitians, or physical therapists. For example, developing a discharge plan, implementing a wound care protocol, or providing nutritional counseling are collaborative nursing interventions. These interventions may or may not require a health care provider's order, depending on the situation and the scope of practice of the nurse.

Choice D reason:

Evaluative nursing interventions are not a type of intervention, but rather a step in the nursing process. Evaluative nursing interventions are actions that nurses take to assess the outcomes of their care and the effectiveness of their interventions. For example, measuring pain levels, monitoring wound healing, or evaluating patient satisfaction are evaluative nursing interventions. These interventions do not require a health care provider's order.

A. Identify the client's health problems. B. Cluster the assessment data. C. Validate the data with the client. D. Prioritize the health problems

Correct Answer is B

Explanation

Choice A reason:

Identifying the client's health problems is not the first step in formulating a diagnostic statement. The nurse needs to gather and analyze the assessment data before identifying the health problems.

Choice B reason:

Clustering the assessment data is the first step in formulating a diagnostic statement. The nurse groups related data together to identify patterns and relationships that indicate a human response to health conditions or life processes.

Choice C reason:

Validating the data with the client is not the first step in formulating a diagnostic statement. The nurse needs to cluster the data first and then validate it with the client to ensure accuracy and completeness.

Choice D reason:

Prioritizing the health problems is not the first step in formulating a diagnostic statement. The nurse needs to cluster the data first and then identify the health problems before prioritizing them.

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A nurse is evaluating a patient's response to pain medication after surgery. The patient reports that his pain level is 8 out of 10 on a numeric rating scale, despite receiving morphine 10 mg intravenously 30 minutes ago. What should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which type of intervention requires a health care provider's order?

Correct Answer is B

Explanation

A nurse is developing a care plan for a client who has impaired mobility due to a stroke. Which of the following actions should the nurse take first when formulating a diagnostic statement?

Correct Answer is B

Explanation

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