The nurse is caring for two clients who both are in pain due to sickle cell anemia. One of the clients rates the pain as a 7 out of 10 (0 is no pain and 10 is the worst pain possible). This client is moving around easily and is eating well, but has asked for pain medication. Which action by the nurse is most appropriate?
Notify the healthcare provider that this client is faking the pain.
Administer the pain medication if it has been longer than the ordered interval.
Wait 30 minutes and see if the client is still requesting pain medicine.
Administer half the ordered dose of pain medication.
The Correct Answer is B
Pain is a subjective experience, and the client's report of pain should be respected and addressed promptly. If the pain medication is ordered and it has been longer than the ordered interval, the nurse should administer the medication as prescribed. In general, withholding pain medication for a client in pain is not an appropriate action.
Administering half the ordered dose of pain medication without a healthcare provider's order is also not appropriate. The nurse should follow the healthcare provider's orders for pain medication administration and titration.
It's also not appropriate to assume that the client is faking pain without adequate assessment and evidence to support such a claim. The nurse should perform a thorough pain assessment, including the location, intensity, and quality of the pain, and consider non-pharmacological interventions to help manage the pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Circumduction is a movement that involves the circular rotation of a limb, such as an arm or leg, around a fixed point. When assessing the patient's range of motion, the nurse may ask the patient to perform circumduction of their arms to evaluate their ability to move their arms in a circular motion.
Correct Answer is B
Explanation
The appropriate next step would be to auscultate for another 4 minutes. The absence of bowel sounds for one minute does not necessarily indicate a surgical emergency, as bowel sounds may be affected by various factors such as the client's diet, medications, and level of activity. Listening for another minute may not provide enough information to make an accurate assessment, so it is recommended to listen for a longer period. If after the additional 4 minutes, there are still no bowel sounds heard, the nurse should notify the physician to further evaluate the client. Listening posteriorly may also provide additional information, but it should be done after the nurse has completed listening to all four quadrants of the abdomen anteriorly.
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