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. Explain that alternative treatment options may be helpful is not appropriate at this moment. The spouse is expressing grief, and the focus should be on emotional support rather than discussing medical treatment options, which may not be relevant to the spouse’s current emotional state.

B. Offer reassurance that the spouse is not alone may provide some comfort but does not address the underlying need for the spouse to express their emotions. It is more important to listen and allow the spouse to share their feelings first.

C. Encourage the spouse to share their feelings is the most appropriate first response. The spouse is expressing emotional distress, and the nurse should offer a safe space for the spouse to talk about their feelings. This approach helps to validate the spouse’s emotions and provides an opportunity for emotional support.

D. Remind the spouse that the client may still live a long time is not appropriate because it could invalidate the spouse’s feelings of loss and grief. The spouse is dealing with the reality of the terminal illness, and the nurse should not offer false hope or minimize the situation.

A. Commend the client for her patience after a long wait in the admission process. B. Determine the client's decision about homologous blood transfusion. C. Arrange for a ritual meeting together with other Jehovah's Witnesses before surgery. D. Obtain primary source of information from the head of the spiritual group.

Correct Answer is B

Explanation

A. Commend the client for her patience after a long wait in the admission process is not appropriate at this time. While acknowledging the client's feelings is important, it is not the most relevant or immediate intervention for this situation.

B. Determine the client's decision about homologous blood transfusion is the most important action. Jehovah's Witnesses generally refuse blood transfusions based on their religious beliefs. The nurse should assess the client’s wishes regarding blood transfusions to ensure informed consent and respect for her beliefs.

C. Arrange for a ritual meeting together with other Jehovah's Witnesses before surgery is not the most immediate action. While spiritual support is important, the priority is addressing the client’s medical decisions, particularly regarding blood transfusions, which may impact her care.

D. Obtain primary source of information from the head of the spiritual group is unnecessary. The client herself is the primary source of information about her beliefs and preferences, and the nurse should focus on her individual decisions rather than seeking information from a religious leader.

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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 client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

Correct Answer is C

Explanation

The nurse is conducting an initial admission assessment for a woman who is a Jehovah's Witness and is scheduled to deliver a baby by Cesarean section within the next 24 hours. Which action should the nurse take?

Correct Answer is B

Explanation

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