It is most important to assign which client to a registered nurse rather than a practical nurse (PN)?
One hour after receiving hydromorphone prescribed for every 4 hours PRN use, a client reports severe pain.
Two hours after receiving morphine for acute pain, a client's vital signs are BP 112/60 mm Hg, pulse 88 beats/minute, and respirations 14 breaths/minute.
After ambulating, a postoperative client grimaces and reports incisional pain at a "9 on a ten-point scale".
The fentanyl transdermal patch for a client with chronic cancer pain needs to be replaced.
The Correct Answer is C
Choice A Reason: This client may need another dose of hydromorphone if the pain is not relieved by the previous one. A PN can administer this medication under the supervision of a RN and monitor the client's response.
Choice B Reason: This client's vital signs are within normal limits and indicate that the morphine is effective and not causing respiratory depression. A PN can assess and document the client's vital signs and pain level.
Choice C Reason: This is the correct answer because this client has acute and severe pain that may require immediate intervention and reassessment. An RN can evaluate the cause and severity of the pain, administer additional analgesics as prescribed, and implement nonpharmacological measures to relieve the pain.
Choice D Reason: This client has chronic and stable pain that is managed by a fentanyl patch. A PN can replace the patch according to the schedule and instructions provided by the RN.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This action is not a priority, as it may delay the response to a potential fire. The charge nurse should assume that the fire alarm is real and act accordingly.
Choice B Reason: This action may expose the clients' family members to smoke or fire, as the visitor waiting area may not be safe. The charge nurse should ensure that everyone is in a protected area.
Choice C Reason: This action may be dangerous, as the stairs may be filled with smoke or fire. The charge nurse should follow the hospital's fire safety protocol, which usually involves closing doors, windows, and vents to prevent the spread of fire.
Choice D Reason: This action is the most appropriate, as it follows the RACE acronym for fire safety: Rescue anyone in immediate danger, Alarm by activating the fire alarm system, Contain by closing doors and windows, and Extinguish or evacuate as directed.
Correct Answer is B
Explanation
Choice A Reason: The initial administration of the analgesic is not an intervention that the charge nurse should counsel the nurse about. The opioid analgesic was prescribed by the healthcare provider and was appropriate for the postoperative pain management of the client.
Choice B Reason: The decision regarding when to call the healthcare provider is an intervention that the charge nurse should counsel the nurse about. The nurse should have called the healthcare provider as soon as the client's
respiratory rate decreased to 6 breaths/minute, which is a sign of opioid-induced respiratory depression. Waiting for another 30 minutes until the respiratory rate decreased to 4 breaths/minute could have put the client at risk of hypoxia, brain damage, or death.
Choice C Reason: The documentation of the client's respiratory rate is not an intervention that the charge nurse should counsel the nurse about. The nurse documented the client's respiratory rate accurately and timely, which is part of the standard of care and legal responsibility of the nurse.
Choice D Reason: The administration of naloxone via IV is not an intervention that the charge nurse should counsel the nurse about. Naloxone is an opioid antagonist that reverses the effects of opioids and restores normal respiration. Administering naloxone via IV is the fastest and most effective way to treat opioid-induced respiratory depression.
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