The nurse is performing an admission assessment on a stable patient admitted after a motor vehicle accident.
The patient reports having bad pain.
What will the nurse do first?
Attempt to determine what type of pain the patient has.
Request an order for intravenous opioid analgesic.
Administer acetaminophen (Tylenol).
Ask the patient to rate the pain on a scale of 1-10.
The Correct Answer is D
Choice A rationale
Determining the type of pain is secondary to assessing pain severity.
Choice B rationale
Intravenous opioids are strong and should be considered only after evaluating pain severity.
Choice C rationale
Administering acetaminophen without assessing pain severity first is not appropriate.
Choice D rationale
Asking the patient to rate their pain helps gauge severity, guiding further pain management steps.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Asking the patient what time of day the medication is taken can help identify if taking it at a different time might alleviate sleep disturbances. SSRIs like sertraline can cause insomnia if taken later in the day.
Choice B rationale
Recommending a weekly dosage is inappropriate and could potentially disrupt the therapeutic effect. SSRIs should be taken daily, as prescribed.
Choice C rationale
Counseling the patient to take the medication at bedtime could worsen sleep disturbances, as sertraline may cause insomnia in some individuals. Timing should be adjusted based on patient response.
Choice D rationale
Suggesting a lower dose without consulting the provider may not address the issue effectively and could reduce the efficacy of the medication. Dosage adjustments should be made based on clinical assessment and provider recommendation.
Correct Answer is D
Explanation
Choice A rationale
Vitamin E is an antioxidant and is not indicated to counteract the effects of warfarin. It does not have a role in reversing anticoagulation or managing bleeding. High doses of Vitamin E can actually interfere with clotting and potentially exacerbate bleeding.
Choice B rationale
Protamine Sulfate is an antidote for heparin, not warfarin. It works by neutralizing the effects of heparin, which is an anticoagulant that acts quickly to prevent clot formation. Warfarin works differently and requires a different antidote for its anticoagulant effect.
Choice C rationale
Calcium Gluconate is not an antidote for warfarin. It is typically used in cases of hypocalcemia and can stabilize cardiac membranes in hyperkalemia but has no effect on reversing warfarin-induced anticoagulation or bleeding.
Choice D rationale
Vitamin K is the correct antidote for warfarin. It counteracts the anticoagulant effects by promoting the synthesis of clotting factors that warfarin inhibits. Administering Vitamin K is standard practice in reversing the effects of warfarin and managing bleeding complications.
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