Which of the following nursing assessments would be the priority when considering the administration of pain medication to a client experiencing acute pain?
Shallow breathing
Blood pressure
Pain intensity level
Heart rate
The Correct Answer is C
Choice A reason: Shallow breathing may indicate respiratory depression, a concern with opioids, but assessing pain intensity is the priority to determine the need for medication need. Pain level guides safe dosing, ensuring appropriate relief without overmedicating, making this a secondary assessment in acute pain.
Choice B reason: Blood pressure may rise with pain but is less specific than pain intensity for guiding medication administration. Pain level directly informs the need for and dose of analgesia, while blood pressure changes can have multiple causes, making this less critical.
Choice C reason
d): Assessing pain intensity level is the priority, as it quantifies the client’s subjective experience using a scale (e.g., 0-10 scale)), determining the need for and dose of pain medication. This ensures effective, patient-centered pain management, making it the most critical assessment before administering medication.
Choice D reason: Heart rate may increase with pain, but it is not the priority compared to pain intensity, which directly drives medication decisions. Heart rate changes are less specific and can result from other factors (e.g., anxiety), making this a secondary assessment in acute pain management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Stage 3 NREM (deep sleep) is characterized by difficulty awakening, as the body is in a restorative state with slow brain waves (delta waves). This makes it hard to rouse the patient, aligning with the physiological features of deep sleep, making this the correct finding.
Choice B reason: Awakening easily is typical of stage 1 or 2 NREM, not stage 3, where deep sleep makes arousal difficult. This finding is inconsistent with the slow-wave, restorative nature of stage 3 NREM, making it incorrect.
Choice C reason: Rapid eye movement occurs in REM sleep, not stage 3 NREM, which is a non-REM, slow-wave sleep phase without eye movement. This finding is specific to REM, making it incorrect for stage 3 NREM assessment.
Choice D reason: Elevated vital signs are not typical of stage 3 NREM, where the body is relaxed, with decreased heart rate and respiration. Elevated vital signs may occur in REM or wakefulness, making this an incorrect finding for deep sleep.
Correct Answer is C
Explanation
Choice A reason: Sleeping pills relax airway muscles, worsening apnea episodes in obstructive sleep apnea. This statement indicates misunderstanding, as sedatives exacerbate the condition, making it incorrect for reducing episodes.
Choice B reason: Avoiding back sleeping (supine position) may reduce episodes, as it minimizes airway collapse. While helpful, weight loss has a greater impact, making this less comprehensive than the correct choice.
Choice C reason: Losing 50 pounds reduces neck fat, decreasing airway obstruction in obstructive sleep apnea. Weight loss is a primary intervention, and this statement shows understanding, making it the correct choice.
Choice D reason: A humidifier improves comfort but does not address airway obstruction causing apnea. Weight loss directly reduces episodes, making humidifier use less effective and incorrect for this teaching.
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