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: Confronting the nurse manager as a group may not be effective or appropriate, as it may create more conflict and resentment. The charge nurse should follow the chain of command and escalate the issue to a higher authority if the nurse manager fails to act.
Choice B reason: Attending procedures performed by the surgeon and demanding halting of the procedure if the client becomes distressed may be seen as insubordination and interference by the surgeon, who may have legal authority to perform the procedure. It may also jeopardize the client's safety and outcome.
Choice C reason: Documenting client reactions to invasive procedures performed by the physician in their medical record is important, but not sufficient. It does not address the root cause of the problem, which is the surgeon's lack of empathy and respect for clients' pain and dignity.
Choice D reason: Reporting the physician's lack of concern for clients' pain during invasive procedures to the Director of Nursing is the most important action for the charge nurse to take, as it may lead to an investigation and corrective measures. The Director of Nursing has more power and responsibility than the nurse manager to deal with such issues and protect clients' rights and welfare.
Correct Answer is A
Explanation
Choice A Reason: This is the correct answer because the client's vital signs indicate that she is hypovolemic and dehydrated due to the leakage of gastric contents from the anastomosis site. The nurse should replace fluids intravenously to prevent shock and electrolyte imbalance.
Choice B Reason: Recording the amount of daily wound drainage is important but not the most important intervention for this client because it does not address the immediate problem of fluid loss and hypovolemia. The nurse should monitor the wound drainage for signs of infection and report any changes to the physician.
Choice C Reason: Assessing skin condition and turgor for breakdown is important but not the most important intervention for this client because it does not address the immediate problem of fluid loss and hypovolemia. The nurse should assess the skin for signs of dehydration and pressure ulcers and provide appropriate skin care.
Choice D Reason: Turning every 2 hours around the clock from side-to-side is important but not the most important intervention for this client because it does not address the immediate problem of fluid loss and hypovolemia. The nurse should turn the client to prevent complications such as pneumonia and atelectasis but also consider the client's comfort and pain level.
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