In the nursing process, evaluating the effectiveness of pain management interventions involves which of the following?
Conducting a new comprehensive medical history
Reassessing patient pain level and functionality
Administering additional interventions from another category
Assuring the patient always takes medications consistently
The Correct Answer is B
A. Conducting a new comprehensive medical history: A comprehensive history is part of the initial assessment phase of the nursing process, not the evaluation phase. While new information may emerge, the purpose of evaluation is to measure the response to specific interventions already implemented. It focuses on current outcomes rather than past medical events.
B. Reassessing patient pain level and functionality: Evaluation requires comparing the patient's current status against the established baseline and goals. The nurse must determine if the pain score has decreased and if the patient can now perform essential tasks like deep breathing. This step validates whether the chosen intervention was clinically effective.
C. Administering additional interventions from another category: Implementing new interventions is a part of the planning or implementation phases, not evaluation. Evaluation must occur first to determine if current treatments are failing before new ones are added. Prematurely changing the plan without evaluation leads to fragmented and uncoordinated patient care.
D. Assuring the patient always takes medications consistently: Monitoring medication adherence is an ongoing implementation task rather than an evaluation of the drug's efficacy. Evaluation focuses on the physiological and subjective impact of the drug on the patient's pain. Adherence does not guarantee that the prescribed dose is actually meeting the patient's needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. 50 gtt/min: This rate would deliver the 100 mL infusion in only 30 minutes, which is twice as fast as the prescribed rate. Rapid infusion of certain medications can lead to adverse effects or toxicity. Accurate calculation is essential when an electronic pump is not available.
B. 25 gtt/min: The manual drip rate is calculated by multiplying the total volume (100 mL) by the drop factor (15 gtt/mL) and dividing by the time in minutes (60 min). 1500 divided by 60 equals 25. This ensures the 100 mL is delivered precisely over the 1-hour period.
C. 75 gtt/min: This drip rate would result in the entire volume being infused in approximately 20 minutes. Such a high rate is incorrect for a 1-hour schedule and could cause fluid overload or infusion-related reactions. It significantly exceeds the required delivery speed of 1.67 mL per minute.
D. 60 gtt/min: Setting the rate to 60 drops per minute would infuse the medication in about 25 minutes. This does not align with the prescribed 1-hour duration for the 100 mL volume. Proper use of the drip factor formula prevents such timing errors in manual administration.
Correct Answer is D
Explanation
A. Perform a skin assessment:While skin integrity is important for all patients, it is not the priority intervention for a suspected gastrointestinal infection. A skin assessment does not prevent the transmission of Clostridioides difficilespores to other patients or staff. It is a secondary task in the context of infection control.
B. Implement standard precautions:Standard precautions are used for all patients but are insufficient to contain the hardy spores of C. diff. These spores are resistant to many common disinfectants and require specific barrier methods. Relying only on standard precautions increases the risk of an institutional outbreak.
C. Offer oral rehydration solution:Managing fluid loss is a supportive measure for diarrhea, but it does not address the primary need for source control. The nurse's first priority must be preventing the spread of the pathogen within the healthcare environment. Hydration is important but follows the implementation of isolation protocols.
D. Enforce contact precautions:C. diffis highly transmissible via the feco-oral route and requires gloves, gowns, and dedicated equipment to prevent cross-contamination. Contact precautions are the specific evidence-based intervention required to contain the infectious spores. This protects the safety of the unit and other vulnerable clients.
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