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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.5"]
Explanation
· Convert grams to milligrams: 1 gram = 1000 mg
· Determine the concentration: The vial contains 1000 mg of streptomycin in 2.5 mL of solution.
· Set up a proportion: (Desired dose / Concentration) Volume = Amount to administer
(200 mg / 1000 mg) x 2.5 mL = X mL
· Solve for X: 0.2 x 2.5 mL = 0.5 mL
Correct Answer is D
Explanation
A. Recent serum hemoglobin level of 16 g/dL (160 g/L) is within the normal range and does not indicate an increased risk for falls.
B. Expressed feelings of depression may affect motivation or activity levels but does not directly increase the risk of falls unless it leads to physical symptoms such as fatigue or unsteady gait.
C. Stooped posture with a steady gait might suggest a musculoskeletal issue, but the "steady gait" does not indicate immediate fall risk.
D. Opioid analgesic received one hour ago is the most relevant factor because opioids can cause dizziness, sedation, and impaired coordination, all of which increase the likelihood of falls. The timing of the medication further highlights the need for vigilance.
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