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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A: The nurse should determine the pH value of the aspirated fluid to confirm the placement of the NGT. Gastric aspirate typically has an acidic pH (usually below 5), which indicates that the tube is correctly placed in the stomach.

Choice B: Withdrawing the NGT and reinserting it is not necessary if the pH of the aspirate confirms gastric placement.

Choice C: Connecting the NGT to wall suction is not appropriate until placement has been confirmed with a pH test.

Choice D: Sending the fluid specimen to the lab is not the first step in verifying NGT placement. Checking the pH is a more immediate and reliable method.

A. Resume CPR immediately. B. Obtain an arterial blood gas sample. C. Perform the third defibrillation shock. D. Administer an IV bolus of epinephrine.

Correct Answer is C

Explanation

Choice A: CPR is important but should be performed in conjunction with defibrillation. Since two defibrillation shocks have already been administered, the next step should be another shock.

Choice B : Obtaining an arterial blood gas sample is not the immediate priority when the client is in ventricular fibrillation. Defibrillation should be continued.

Choice C: Performing the third defibrillation shock is the next appropriate step in the advanced cardiac life support (ACLS) algorithm for ventricular fibrillation.

Choice D: Administering an IV bolus of epinephrine may be part of the ACLS protocol, but it is typically administered after defibrillation attempts.

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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?

Nursing Test Bank

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While assessing placement of a nasogastric tube (NGT), the nurse aspirates cloudy green fluid into a syringe. Which intervention should the nurse Implement?

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Correct Answer is C

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