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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A reason:
Asking about the clients' current exercise habits helps the nurse to assess their baseline physical activity levels, their preferences, their strengths, and their areas for improvement. This information can help the nurse to tailor the health promotion interventions to the clients' needs and goals.
Choice B reason:
Asking about the benefits of regular physical activity helps the nurse to evaluate the clients' knowledge and awareness of the positive effects of exercise on their health and well-being. This information can help the nurse to reinforce the clients' motivation and provide education as needed.
Choice C reason:
Asking about the barriers to increasing physical activity helps the nurse to identify the factors that may prevent or hinder the clients from engaging in exercise. These factors may include lack of time, resources, support, or confidence. This information can help the nurse to address the clients' concerns and challenges and help them find solutions.
Choice D reason:
Asking about the strategies to overcome the barriers helps the nurse to empower the clients to take action and make changes in their behavior. The nurse can help the clients to develop realistic and specific plans that suit their abilities and preferences. The nurse can also provide support and encouragement along the way.
Choice E reason:
Asking about the potential complications of physical inactivity is not a relevant question to assess the clients' readiness for enhanced fitness. This question may be appropriate for secondary or tertiary prevention, but not for primary prevention. Primary prevention focuses on promoting health and preventing disease or injury, not on treating or rehabilitating existing problems.
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