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 B

Explanation

A. Apply sterile-strips is not the most appropriate action. Steri-strips are typically used for approximating wound edges or supporting sutures, but they are not the first intervention when there is concern about infection or unusual exudate.

B. Obtain a wound culture is the correct action. A thick tan exudate may indicate infection or an abnormal healing process. The nurse should obtain a wound culture to identify the presence of infection and guide appropriate treatment.

C. Apply a debriding agent is premature without first assessing the wound for infection. Debridement is typically used to remove necrotic tissue, but the priority is to determine whether an infection is present before proceeding with debridement.

D. Remove every other suture is not indicated. Sutures should not be removed unless instructed by the healthcare provider, and there is no indication that sutures need to be removed at this time. The focus should be on assessing the wound for infection first.

A. Whether they contain pulp or fruit. B. The color and flavor of gelatin used. C. How many popsicles are available. D. If the popsicles are completely frozen.

Correct Answer is B

Explanation

A. Whether they contain pulp or fruit is unnecessary to assess because flavored gelatin is typically free of pulp or fruit. The concern lies more with the appropriateness of the ingredients as clear liquids.

B. The color and flavor of gelatin used is the correct response because some colored gelatins (e.g., red or purple) can mimic blood if vomiting occurs, potentially leading to misinterpretation of the child’s condition. The nurse should ensure that the parent uses neutral or light-colored gelatin (e.g., yellow or clear).

C. How many popsicles are available is not relevant to the appropriateness of the popsicles as a clear liquid or their potential effects on the child’s condition.

D. If the popsicles are completely frozen is not significant as long as the popsicles are made from appropriate clear liquids.

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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

A surgical incision that is healing by secondary intention develops a thick tan exudate. Which action should the nurse take first?

Correct Answer is B

Explanation

A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?

Correct Answer is B

Explanation

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