The practical nurse (PN) observes a male client grimacing and holding his head. The PN determines that the client is in pain. To validate this assessment with subjective data, which action should the PN implement?
Ask the client to provide a detailed description about the quality of the pain.
Review the medication record and note when the client last received an analgesic.
Compare the client's current vital signs with vital signs taken earlier in the day.
Consult with the charge nurse about the manifestations that the client is exhibiting.
The Correct Answer is A
A. Ask the client to provide a detailed description about the quality of the pain: Subjective data are obtained directly from the client’s verbal report. Asking the client to describe the pain’s quality, intensity, and location validates the nurse’s observation and provides essential information for accurate pain assessment and management.
B. Review the medication record and note when the client last received an analgesic: This provides objective data about pain management but does not validate the client’s current pain experience, which must come from the client’s own report.
C. Compare the client’s current vital signs with vital signs taken earlier in the day: Changes in vital signs, such as increased pulse or blood pressure, are objective indicators of pain, but they cannot confirm the client’s subjective experience.
D. Consult with the charge nurse about the manifestations that the client is exhibiting: Discussing observations with another nurse may be appropriate later, but validation of pain requires direct communication with the client, not secondary consultation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1"]
Explanation
Determine the volume to administer in milliliters (mL).
Prescribed dose = 30 mg
Available concentration = 30 mg per 15 mL
Volume (mL) to administer = (Prescribed dose (mg) / Available concentration (mg)) x Available volume (mL)
= (30 mg / 30 mg) x 15 mL
= 15 mL.
Convert the volume from milliliters (mL) to tablespoons (tbsp).
Conversion factor: 1 tablespoon (tbsp) = 15 mL
Volume (tbsp) = (Volume in mL / Conversion factor)
= (15 mL / 15 mL/tbsp)
= 1 tbsp.
Correct Answer is D
Explanation
A. Confirm that the medication is only administered once daily: The frequency of administration is verified when reviewing the prescription, not during the administration process. This step does not address the observed technique or ensure safe practice.
B. Determine if the medication is compatible with the solution: Checking compatibility is important before mixing medications with enteral feedings, but the question focuses on the PN’s observation of an improper administration technique, requiring immediate intervention.
C. Offer to assist in calculating the rate of flow for the mixture: Liquid medications given via feeding tubes are not typically infused at a specific rate but administered separately from feedings to prevent interaction or tube blockage, so rate calculation is unnecessary.
D. Demonstrate how to administer medication via a feeding tube: The appropriate response is to stop the incorrect procedure and demonstrate proper technique. Medications should be given separately from feedings, flushed with water before and after, and never mixed directly into the feeding solution.
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