The nurse is administering pain medication for several patients. Which patient does the nurse administer medication to first?
The patient who has a PCA running that needs the syringe replaced.
The patient who needs to be pre-medicated before walking.
The patient who is experiencing 8/10 pain and has an immediate order for pain medication
The patient who needs to take a scheduled dose of maintenance pain medication
The Correct Answer is C
Choice A reason: Replacing a PCA syringe ensures continued pain control but is less urgent than acute severe pain. PCA systems often have residual medication, allowing a brief delay without compromising pain management, so this is not the priority.
Choice B reason: Pre-medicating before walking prevents pain exacerbation but is less critical than addressing existing severe pain. Scheduled mobility can be delayed slightly to prioritize acute needs, making this a lower priority intervention.
Choice C reason: A patient with 8/10 pain and an immediate order indicates acute, severe distress requiring urgent intervention. Severe pain can elevate stress hormones, heart rate, and blood pressure, necessitating prompt medication to stabilize the patient and alleviate suffering.
Choice D reason: Scheduled maintenance medication maintains baseline pain control but is not urgent compared to acute 8/10 pain. Delaying a scheduled dose briefly is less likely to cause harm than untreated severe pain, making this a lower priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Offering narcotics immediately without assessing pain details or considering nonpharmacological options is not therapeutic. Pain management requires a tailored approach, evaluating pain characteristics and patient preferences, as narcotics carry risks like respiratory depression, especially post-surgery, necessitating cautious use.
Choice B reason: Dismissing pain based on stable vitals is not therapeutic. Pain is subjective, and normal vitals (e.g., 110/60 mmHg, 60 bpm) don’t negate severe pain. This response invalidates the patient’s experience, potentially eroding trust and delaying effective pain management.
Choice C reason: Stating the patient doesn’t look in pain is dismissive and non-therapeutic. Pain is subjective, and external appearance may not reflect internal experience, especially in stoic patients. This response risks undermining patient trust and delaying appropriate pain relief interventions.
Choice D reason: Asking what the patient wants to try is therapeutic, promoting patient-centered care. It validates the patient’s pain, encourages shared decision-making, and considers both pharmacological and nonpharmacological options, optimizing pain relief while respecting patient autonomy and preferences post-surgery.
Correct Answer is B
Explanation
Choice A reason: Offering the bedpan every 2 hours does not directly stimulate peristalsis. While regular toileting may prevent constipation, it lacks the mechanical or physiological stimulus needed to enhance bowel motility, especially in postoperative patients at risk for paralytic ileus.
Choice B reason: Ambulation promotes peristalsis by stimulating abdominal muscles and increasing intra-abdominal pressure, which encourages bowel motility. Early mobilization post-surgery enhances blood flow to the gastrointestinal tract, reducing the risk of paralytic ileus by counteracting slowed motility from anesthesia or immobility.
Choice C reason: Increasing protein intake supports tissue repair but does not directly stimulate peristalsis. Protein metabolism may increase stool bulk over time, but it lacks the immediate mechanical or neural stimulation needed to prevent or treat paralytic ileus in the postoperative period.
Choice D reason: Decreasing fluid intake can worsen bowel motility by reducing stool hydration, leading to harder stools and increased risk of constipation. Adequate hydration is essential for maintaining soft stool and supporting peristalsis, making this intervention counterproductive.
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