Two clients ring their call lights simultaneously requesting pain medication. Which action should the nurse implement first?

Determine when each client last received pain medication.

Evaluate both clients' pain using a standardized pain scale.

Provide nonpharmacologic pain management interventions.

Prepare both clients' medication and take to them at once.

Answer and Explanation

The Correct Answer is B

A. Determine when each client last received pain medication is an important step in managing pain, but it does not address the immediate need to evaluate the severity of the clients' pain. Knowing when they last received pain medication can help with medication timing but should follow a thorough assessment.

B. Evaluate both clients' pain using a standardized pain scale is the most appropriate first action. This allows the nurse to assess the severity of each client’s pain and prioritize which client requires more immediate attention. Pain severity, rather than timing of medication, should guide the nurse's intervention.

C. Provide nonpharmacologic pain management interventions can be helpful, but it does not address the immediate need for assessing and addressing the severity of pain. Nonpharmacologic interventions can be used as an adjunct but should not replace proper assessment and pharmacologic management if necessary.

D. Prepare both clients' medication and take to them at once could lead to a delay in addressing the most severe pain. It is important to assess pain levels first to prioritize care, as one client may require medication sooner than the other.

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Correct Answer is C

Explanation

A. Prescription for ceftriaxone PO every 12 hours is not relevant in the initial "Situation" section of SBAR. This would fit better under the "Recommendation" or "Background" sections.

B. A 26-year-old client is part of the background information but does not immediately address the critical issue requiring attention.

C. Blood pressure is 80/48 mm Hg is the most urgent information and provides a clear reason for contacting the healthcare provider.

D. Admitted after a motor vehicle collision is part of the background and would follow the situation statement.

A. Provide a box of tissues for the client to use when coughing. B. Obtain face masks for staff to wear upon entering the room. C. Assist the client in changing into a fresh hospital gown. D. Teach the client to cover the mouth with hands when coughing.

Correct Answer is B

Explanation

A. Provide a box of tissues for the client to use when coughing is a helpful action for promoting hygiene and comfort. However, this does not address the potential risk of infection transmission to staff and others in the room.

B. Obtain face masks for staff to wear upon entering the room is the most appropriate action. The client is coughing, and non-productive coughing can still release droplets that may carry infectious agents. Wearing face masks helps protect staff and other individuals from potential exposure to airborne pathogens.

C. Assist the client in changing into a fresh hospital gown is a considerate action but does not directly address the immediate concern of infection control. The priority here is preventing the spread of potential infectious particles.

D. Teach the client to cover the mouth with hands when coughing is incorrect. The client should cover their cough with their elbow or a tissue, not with their hands, to prevent spreading germs. Teaching this technique is important but does not address the immediate need for protective measures for staff.

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Two clients ring their call lights simultaneously requesting pain medication. Which action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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