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. Capillary refill time is 2 seconds is within the normal range and is unlikely to interfere with the pulse oximeter reading.

B. 2+ edema of fingers and hands most likely contributes to the low oxygen saturation reading. Edema can impair the accuracy of a pulse oximeter by affecting the transmission of light through the tissues, leading to erroneous readings.

C. Blood pressure is 142/88 mm Hg is mildly elevated but does not directly affect the pulse oximeter's ability to measure oxygen saturation.

D. Radial pulse volume is 3+ indicates a strong pulse and does not interfere with the functionality of the pulse oximeter.

A. Clamping the urinary catheter prior to the collection. B. Using the syringe to remove the specimen from the catheter. C. Recording the output on the flowsheet in the client's room. D. Transporting the urine specimen to the laboratory.

Correct Answer is B

Explanation

A. Clamping the urinary catheter prior to the collection is typically done with clean hands, as the nurse is preparing the catheter for specimen collection. Gloves are not required for this step, as long as proper hand hygiene is performed before and after.

B. Using the syringe to remove the specimen from the catheter is the correct time for the nurse to wear gloves. This step involves direct contact with potentially contaminated urine, and gloves are necessary to maintain infection control and protect the nurse from exposure to bodily fluids.

C. Recording the output on the flowsheet in the client's room does not require gloves, as this step does not involve direct contact with the urine. The nurse should perform proper hand hygiene before and after documenting the output.

D. Transporting the urine specimen to the laboratory does not require gloves, as the specimen is contained in a biohazard bag. Gloves are typically worn during the collection process, but transporting a properly sealed specimen does not require additional protection.

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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

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

Correct Answer is B

Explanation

The nurse uses a sterile syringe to obtain a urine specimen from a client's indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear gloves?

Correct Answer is B

Explanation

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