Choice A rationale
If a patient’s pain level remains high despite receiving regular doses of fentanyl, it may indicate
that the current dose is insufficient. The PN should report this to the healthcare provider, who
may decide to increase the dose.
Choice B rationale
While it’s important to continue monitoring the patient and assessing the pain level, this alone
may not be sufficient if the patient’s pain remains uncontrolled.
Choice C rationale
Non-pharmacological methods of pain control can be beneficial, but they are typically used in
conjunction with medication, not as a replacement for it when the pain level is high.
Choice D rationale
Informing the patient about the potential addictiveness of the medication is important, but it’s
not the most appropriate action to take in response to uncontrolled pain.

Choice A rationale

Involuntary movements of the lips and tongue are typically associated with antipsychotic medications, not nonsteroidal anti-inflammatory drugs (NSAIDs) like ketorolac15. Therefore, observing the client for these symptoms would not be a relevant intervention for a client taking ketorolac15.

Choice B rationale

Administering the medication at least 30 minutes before meals is not a specific requirement for ketorolac15. Therefore, this would not be a necessary intervention for a client taking this medication15.

Choice C rationale

Ketorolac, like other NSAIDs, can increase the risk of bleeding15. This can manifest as areas of ecchymosis (bruising) or other signs of bleeding on the skin15. Therefore, assessing the skin daily for these signs would be an important intervention for a client taking ketorolac15.

Choice D rationale

Peak and trough serum levels are typically monitored for medications with a narrow therapeutic index, such as certain antibiotics15. Ketorolac does not typically require

monitoring of serum levels15. Therefore, ensuring peak and trough serum levels are collected would not be a necessary intervention for a client taking this medication15.