Which six factors should the nurse consider when choosing a time frame for reassessing the patient’s pain level after implementing pain management?
Agency policy
Type of intervention
Pain severity
If family members are present in the patient’s room
The patient’s psychosocial condition
Risks for adverse effects
Workload of the nurse
The patient’s physical condition
Correct Answer : B,C,E,F,H
Choice A: Agency policy
While agency policy provides guidelines for reassessment intervals, it is not the primary factor in determining the specific time frame for reassessing a patient’s pain level. Policies serve as a general framework, but individual patient needs and clinical judgment should guide the reassessment timing.
Choice B: Type of intervention
This is a correct answer. The type of pain management intervention used significantly influences the reassessment time frame. For example, after administering intravenous pain medication, reassessment should occur sooner compared to oral medications due to the faster onset of action. Different interventions have varying durations of effectiveness, necessitating tailored reassessment intervals.
Choice C: Pain severity
This is another correct answer. The severity of the patient’s pain is a crucial factor in determining reassessment timing. Patients experiencing severe pain may require more frequent reassessments to ensure that pain management strategies are effective and to make timely adjustments if needed.
Choice D: If family members are present in the patient’s room
The presence of family members in the patient’s room is not a primary factor in determining the reassessment time frame. While family members can provide valuable support and information, the focus should remain on the patient’s clinical needs and the effectiveness of pain management interventions.
Choice E: The patient’s psychosocial condition
This is a correct answer. The patient’s psychosocial condition, including their emotional and mental state, can impact their perception of pain and response to pain management. Patients with anxiety, depression, or other psychosocial issues may require more frequent reassessments to address both physical and emotional aspects of pain.
Choice F: Risks for adverse effects
This is also a correct answer. The potential for adverse effects from pain management interventions necessitates careful monitoring and timely reassessment. For instance, opioids carry risks of respiratory depression and sedation, requiring close observation and frequent reassessment to ensure patient safety.
Choice G: Workload of the nurse
While the nurse’s workload can influence the practical aspects of care delivery, it should not dictate the reassessment time frame. Patient needs and clinical priorities should guide reassessment intervals, with workload management being a secondary consideration.
Choice H: The patient’s physical condition
This is the final correct answer. The patient’s overall physical condition, including comorbidities and current health status, affects their response to pain management and the need for reassessment. Patients with complex medical conditions may require more frequent monitoring to ensure effective pain control and to promptly address any complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Peripheral pulses
Monitoring peripheral pulses is important for assessing circulation and detecting any signs of vascular complications. However, it is not the most critical assessment for a patient receiving 3% NaCl for hyponatremia. The primary concern with hypertonic saline infusion is the risk of fluid overload and central nervous system (CNS) complications.
Choice B: Urinary output
Monitoring urinary output is essential for assessing kidney function and fluid balance. While it is important, it is not the most critical assessment in this scenario. The primary risks associated with 3% NaCl infusion include rapid changes in serum sodium levels and potential CNS complications.
Choice C: Peripheral edema
Peripheral edema can indicate fluid overload, but it is not the most immediate concern when administering hypertonic saline. The nurse should prioritize monitoring for signs of pulmonary edema and neurological changes, which can occur more rapidly and have more severe consequences.
Choice D: Lung sounds and neurological status
Monitoring lung sounds and neurological status is the most important assessment for a patient receiving 3% NaCl for hyponatremia. Hypertonic saline can cause rapid shifts in fluid balance, leading to pulmonary edema and neurological complications such as osmotic demyelination syndrome. Assessing lung sounds helps detect early signs of fluid overload in the lungs, while monitoring neurological status helps identify any changes in mental status or neurological function that could indicate serious complications.
Correct Answer is A
Explanation
Choice A: Infuse the KCl at a maximum rate of 10 mEq/hr
This is the correct answer. The recommended infusion rate for potassium chloride is generally not to exceed 10 mEq per hour to avoid complications such as hyperkalemia and cardiac arrhythmias. This rate ensures that the potassium is administered safely and effectively, allowing for proper monitoring and adjustment if necessary.
Choice B: Discontinue cardiac monitoring during the infusion
This choice is incorrect. Cardiac monitoring is essential during the infusion of potassium chloride, especially in patients with severe hypokalemia, due to the risk of arrhythmias and other cardiac complications. Continuous monitoring allows for the early detection of any adverse effects and timely intervention.
Choice C: Administer the KCl as a rapid IV bolus
Administering potassium chloride as a rapid IV bolus is dangerous and contraindicated. Rapid infusion can lead to severe hyperkalemia, which can cause fatal cardiac arrhythmias. Potassium chloride should always be administered slowly and diluted in an appropriate volume of fluid.
Choice D: Refuse to give the KCl through a peripheral venous line
While central lines are preferred for higher concentrations of potassium chloride due to the risk of irritation and phlebitis, peripheral lines can be used for lower concentrations and slower infusion rates. Refusing to administer potassium chloride through a peripheral line is not necessary if the infusion is properly managed and monitored.
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