Aspirin 81 mg at 0900 daily is prescribed for an adult client. At 0800 the client asks for something for low back pain, but does not have any PRN analgesics prescribed. Which action is best for the nurse to take?
Wait until 0830 and administer the aspirin.
Obtain a prescription for a PRN analgesic.
Assess the client's prothrombin time (PT)/international normalized ration (INR).
Administer the prescribed daily aspirin now.
The Correct Answer is B
Choice A rationale: Waiting until 0830 and administering the aspirin would not address the client's immediate need for pain relief.
Choice B rationale: Obtaining a prescription for a PRN analgesic is the most appropriate action to provide the client with effective pain relief.
Choice C rationale: Assessing the client's prothrombin time (PT)/international normalized ratio (INR) is not necessary in this context and does not address the immediate pain concern.
Choice D rationale: Administering the prescribed daily aspirin now would not address the client’s lower back pain at the moment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: The initial administration of the opioid analgesic is appropriate as long as the nurse adheres to the prescription made.
Choice B rationale: Administering naloxone via IV is an appropriate intervention to reverse the effects of opioid toxicity. It is not the focus of counseling in this scenario.
Choice C rationale: The nurse should have notified the healthcare provider as soon as the client's respiratory rate decreased to 6 breaths/minute, which is a sign of respiratory depression caused by the opioid analgesic. The nurse should not have waited until the client's respiratory rate decreased to 4 breaths/minute, which is a life-threatening condition that requires immediate intervention.
Choice D rationale: Documentation of the client's respiratory rate is essential for monitoring, and there is no indication that the documentation was inappropriate.
Correct Answer is A
Explanation
Choice A rationale: The immediate priority during a fire alarm is to ensure the safety of clients and staff. Instructing everyone to stay in the client rooms with doors closed helps contain any potential smoke or fire, providing protection while the situation is assessed.
Choice B rationale: Instructing family members to stay in the waiting area might not be the primary concern during a fire alarm. The focus is on the safety of clients and staff.
Choice C rationale: While determining the nature of the emergency is important, taking immediate actions to ensure safety is the priority. The charge nurse can address the cause once the safety of individuals is secured.
Choice D rationale: Evacuating clients should only be considered if it is determined to be safe to do so. It's crucial to assess the situation and follow established protocols before initiating evacuation.
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