The nurse administers a pain medication via IM injection to the patient. When should the nurse re-assess the patient's pain level?
10 minutes after administration
After 2 hours
Within 1 hour
Once a shift
The Correct Answer is C
Intramuscular analgesic administration involves deposition of medication into skeletal muscle tissue allowing systemic absorption through capillary perfusion, producing onset dependent on drug class, lipid solubility, and circulation with expected analgesic effect occurring within defined pharmacokinetic time window requiring reassessment.
Rationale:
A. 10 minutes after intramuscular injection is too early for most analgesics to reach therapeutic plasma concentration. IM absorption requires vascular uptake and systemic distribution. Pain relief is usually not fully established at this time, making assessment premature and unreliable for efficacy evaluation.
B. 2 hours may be appropriate for some long-acting analgesics, but it exceeds the recommended initial reassessment window for most IM pain medications. Delayed evaluation risks prolonged untreated pain. Clinical guidelines emphasize earlier reassessment to ensure timely dose adjustment or additional intervention if needed.
C. Within 1 hour is the standard reassessment time for most IM analgesics as peak effect typically occurs within this period depending on drug type. This allows evaluation of analgesic efficacy and detection of inadequate pain control for timely clinical intervention or dose adjustment.
D. Once a shift is inappropriate for acute pain management following IM administration. Pain must be reassessed shortly after drug absorption begins, not at prolonged intervals. This approach risks uncontrolled pain, delayed response evaluation, and failure to meet effective pain management standards in clinical care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Sensorineural hearing loss results from permanent damage to the cochlear hair cells or the vestibulocochlear nerve pathways. Chronic exposure to high-intensity sound waves induces metabolic exhaustion and mechanical strain, leading to the apoptosis of the organ of Corti. This irreversible condition disrupts the transduction of mechanical vibrations into electrical neural impulses.
Rationale:
A. Earwax impaction causes conductive hearing loss by physically obstructing the external auditory canal. It prevents sound waves from reaching the tympanic membrane but does not damage the inner ear. This is a reversible condition and is not classified as a sensorineural pathology.
B. Seasonal allergies and sinus infections typically lead to Eustachian tube dysfunction and fluid accumulation in the middle ear. This results in conductive impairment due to inhibited ossicle vibration. These inflammatory processes do not typically affect the neurosensory components of the auditory system located within the bony labyrinth.
C. Prolonged exposure to occupational noise is the leading cause of acquired sensorineural deficits. High decibel levels cause oxidative stress and structural shearing of the delicate stereocilia. This finding is the most significant risk factor for permanent damage to the sensory receptors of the inner ear.
D. Recurrent otitis media and tympanic scarring, or tympanosclerosis, interfere with the mechanical transmission of sound through the middle ear. These issues cause conductive loss by reducing the compliance of the eardrum. They are structural issues of the conducting apparatus rather than the neural processing units of the ear.
Correct Answer is A
Explanation
Pediatric otoscopic examination depends on correct external auditory canal alignment to allow full visualization of the tympanic membrane. In children under 3 years, the ear canal is shorter, more compliant, and angled differently than in adults due to craniofacial development, requiring specific pinna manipulation to straighten the canal.
Rationale:
A. Pull the pinna down and back is correct for children under 3 years. This maneuver straightens the external auditory canal by compensating for its superior and horizontal orientation in toddlers. It allows optimal visualization of the tympanic membrane without canal distortion or obstruction.
B. Pull the pinna up and back is used in children over 3 years and adults because the ear canal becomes more downward angled with age. Using this technique in a 2-year-old misaligns the canal and reduces visibility of the tympanic membrane during examination.
C. Pull the pinna down and forward does not anatomically straighten the pediatric ear canal. This movement further obstructs visualization and can distort the external auditory canal, making accurate inspection of the tympanic membrane difficult and clinically inappropriate for otoscopic assessment.
D. Pull the pinna up and forward is incorrect because it worsens alignment of the external auditory canal in both pediatric and adult patients. It does not facilitate visualization of the tympanic membrane and is not a recognized otoscopic examination technique.
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