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.

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A rationale: The nurse does not need to determine who is assigned the care of the client, as this is not relevant to the immediate situation.

Choice B rationale: The nurse should not enter the room and quietly observe the interaction, as this would delay the intervention and put the client and the visitor at risk.

Choice C rationale: The nurse should not notify the hospital security department immediately, as this would also delay the intervention and may escalate the situation.

Choice D rationale: The nurse should prioritize the safety of the client and the visitor, and intervene to stop the potential violence. The nurse should instruct the visitor to leave the room immediately, and then assess the client's condition and provide appropriate care.

A. Instruct the UAP to ask the visitor to get off the client's bed. B. Discuss why visitors should not lie in the bed with the client. C. Explain that the client has the right to have a visitor lie on the bed. D. Notify the charge nurse that the visitor is lying on the client's bed.

Correct Answer is C

Explanation

Choice A rationale: Instructing the UAP to ask the visitor to get off the client's bed is not within the UAP's scope of practice and may cause conflict.

Choice B rationale: While education about infection control and respect for the client's environment is important, it's essential to prioritize the client's autonomy and preferences regarding their visitors.

Choice C rationale: Clients have rights to decide who can be in their personal space, including their bed. As long as the visitor is not posing a risk to the client's safety or health, the client's wishes should be respected.

Choice D rationale: Notifying the charge nurse about the visitor lying on the bed is a reasonable action, but the immediate intervention is to ask the visitor to get off the bed.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While walking down the hallway, the nurse finds a female client yelling, swinging her hands, and pushing a male visitor away from her hospital bed. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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