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:

The client states that he has trouble sleeping at night. This is subjective data because it is information that the client shares with the nurse spontaneously or in response to a question. Subjective data is based on the client's perception and feelings.

Choice B reason:

The client has a blood pressure of 150/90 mm Hg. This is objective data because it is information that the nurse observes when conducting a physical assessment. Objective data is measurable and observable.

Choice C reason:

The client reports feeling anxious about his diagnosis. This is subjective data because it is information that the client shares with the nurse spontaneously or in response to a question. Subjective data is based on the client's perception and feelings.

Choice D reason:

The client prefers not to discuss his personal issues. This is subjective data because it is information that the client shares with the nurse spontaneously or in response to a question. Subjective data is based on the client's perception and feelings.

A. The client states that they have a burning sensation when urinating. B. The client has a temperature of 38.2°C (100.8°F) and a pulse of 110/min. C. The client appears restless and anxious during the examination. D. The client reports drinking cranberry juice to prevent UTIs.

Correct Answer is B

Explanation

Choice A reason:

This statement is not objective data because it is based on what the client states, not what the nurse observes or measures. This is an example of subjective data, which is information that depends on personal feelings.

Choice B reason:

This statement is objective data because it is based on what the nurse observes or measures using a thermometer and a pulse oximeter. This is an example of objective data, which is information that is factual and can be verified.

Choice C reason:

This statement is not objective data because it is based on the nurse's interpretation of the client's appearance and behavior, not on direct observation or measurement. This is an example of subjective data, which is information that represents the patient's perceptions, feelings, or concerns.

Choice D reason:

This statement is not objective data because it is based on what the client reports, not what the nurse observes or measures. This is an example of subjective data, which is information that the patient tells the nurse that cannot be measured or observed.

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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

A nurse is documenting the data collected from a comprehensive physical exam of a client. Which of the following data should the nurse identify as objective data?

Correct Answer is B

Explanation

A nurse is documenting the data collected from an assessment of a client who has a urinary tract infection (UTI). Which of the following statements should the nurse use to record objective data?

Correct Answer is B

Explanation

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