An adolescent hospitalized with sickle cell anemia reports to the nurse of experiencing a pain level of 10 on a 0 to 10 numerical scale. The nurse observes the adolescent on a phone call laughing. Which action should the nurse take?
Introduce non-pharmacologic strategies for pain reduction.
Allow adequate privacy and time for the client's phone call.
Document the concern of incongruent pain rating and behavior.
Administer pain medication per the healthcare provider's orders.
The Correct Answer is B
Choice A: Introducing non-pharmacologic strategies for pain reduction is a valid intervention for managing pain in a client with sickle cell anemia. However, in this scenario, the client's laughter on the phone call may not necessarily indicate that the pain level is accurately reflected by the numerical rating. It is essential to consider the client's overall well-being and pain management plan.
Choice B: Allowing adequate privacy and time for the client's phone call is a considerate and appropriate action. It acknowledges the client's need for communication and emotional support, which can be important in managing pain.
Choice C: Documenting the concern of incongruent pain rating and behavior is a necessary step for the nurse to record the observation. However, it should not be the only action taken in response to the situation.
Choice D: Administering pain medication should be based on a comprehensive assessment of the client's pain and the healthcare provider's orders. While pain medication may be indicated for this client, it should not be administered solely based on the numerical pain rating without further assessment and consideration of the client's overall condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Taking the medication before meals is not a specific instruction for anticoagulant therapy. The timing of anticoagulant administration can vary depending on the specific medication and dosing regimen.
Choice B: Using an electric razor when shaving is an important instruction for clients on anticoagulant therapy. Anticoagulants can increase the risk of bleeding, and using a manual razor could lead to cuts or nicks that may be harder to control.
Choice C: Eating green leafy vegetables high in vitamin K is a relevant instruction for clients taking warfarin, an anticoagulant. However, it should be emphasized that consistent intake of vitamin K-rich foods is important to maintain consistent anticoagulation levels, rather than avoiding these foods altogether.
Choice D: Instructing the client to double the next dose if a dose is missed is not appropriate for anticoagulant therapy. Missing a dose should be addressed according to the healthcare provider's guidance and may involve taking the missed dose as soon as remembered or skipping it and continuing with the regular dosing schedule.
Correct Answer is ["6"]
Explanation
To determine the volume of amoxicillin-clavulanic acid suspension to administer in a single dose, you can use the following calculation:
Dose prescribed: 300 mg Concentration available: 250 mg/5 mL
First, calculate the dose per mL:
Dose per mL = Concentration available (mg/mL) Dose per mL = 250 mg/5 mL
Dose per mL = 50 mg/mL
Now, calculate the mL needed for the prescribed dose:
Volume (mL) = Dose prescribed (mg) / Dose per mL Volume (mL) = 300 mg / 50 mg/mL
Volume (mL) = 6 mL
Therefore, the nurse should administer 6 mL of amoxicillin-clavulanic acid suspension in a single dose.
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