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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Free Nursing Study Resources

Correct Answer is ["A","C","D"]

Explanation

Choice A:

Positioning the patient in high Fowler's position. This is a correct intervention because it allows for optimal chest expansion and lung ventilation, reducing dyspnea and work of breathing.

Choice B:

Encouraging deep breathing and coughing exercises. This is an incorrect intervention because it may increase dyspnea and fatigue in a patient with COPD who already has difficulty breathing. Instead, the nurse should teach pursed-lip breathing and diaphragmatic breathing techniques to improve gas exchange and reduce air trapping.

Choice C:

Administering bronchodilators and corticosteroids as ordered. This is a correct intervention because these medications help to relax the smooth muscles of the airways, reduce inflammation, and improve airflow in a patient with COPD.

Choice D:

Providing supplemental oxygen via nasal cannula as ordered. This is a correct intervention because oxygen therapy helps to correct hypoxemia, reduce pulmonary hypertension, and improve exercise tolerance and quality of life in a patient with COPD. The nurse should monitor the oxygen saturation and adjust the flow rate according to the prescription and the patient's response.

Choice E:

Restricting fluid intake to prevent fluid overload. This is an incorrect intervention because fluid restriction is not indicated for a patient with COPD unless there is evidence of heart failure or renal impairment. Adequate hydration helps to thin the secretions and facilitate expectoration in a patient with COPD. The nurse should encourage oral fluids unless contraindicated and monitor the fluid balance and electrolytes of the patient.

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

A nurse is planning care for a patient who has chronic obstructive pulmonary disease (COPD) and is experiencing dyspnea at rest. Which of the following interventions should be included in the plan of care?(Select all that apply.).

Correct Answer is ["A","C","D"]

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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