A client in the surgical recovery area asks the nurse to bring the largest possible dose of pain medication available. Which action should the nurse implement first?

Ask the client to rate the current level of pain using a pain scale.

Encourage the client to use diversional thoughts to manage pain.

Review the history for a past use of recreational drugs.

Determine when the last dose was administered.

Answer and Explanation

The Correct Answer is A

Choice A rationale; When a client requests pain medication, the first action the nurse should take is to assess the client's current pain level. By using a pain scale, the nurse can determine the intensity of the pain and evaluate the need for pain medication appropriately. The pain scale allows the client to express their pain on a standardized scale, helping the nurse to understand the severity of the pain and the most appropriate pain management intervention.

Choice B rationale: While diversional thoughts and non-pharmacological pain management techniques can be useful, the priority is to first assess the pain level and address the client's immediate needs for pain relief.

Choice C rationale: While it's important to consider the client's history of drug use, it is not the first action to take when a client requests pain medication. Assessing the pain level and providing appropriate pain relief should be the initial priority.

Choice D rationale: While it's essential to know the last dose of pain medication the client received, it is not the first action to take when the client is requesting pain medication. Assessing the current pain level and addressing the client's immediate needs should be the first step. The information about the last dose will be relevant for deciding when the next dose can be given.

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Correct Answer is B

Explanation

Choice A rationale: Serum ammonia levels are not relevant to the effectiveness of sodium polystyrene sulfonate in treating hyperkalemia.

Choice B rationale: Sodium polystyrene sulfonate is a medication used to treat hyperkalemia (high potassium levels). A serum potassium level of 3.8 mEq/L falls within the normal reference range (3.5 to 5.0 mEq/L), indicating that the medication has been effective in promoting the excretion of potassium and reducing hyperkalemia.

Choice C rationale: Serum glucose levels are not relevant to the effectiveness of sodium polystyrene sulfonate in treating hyperkalemia.

Choice D rationale: Hemoglobin levels are not relevant to the effectiveness of sodium polystyrene sulfonate in treating hyperkalemia.

A. Advise the client to move slowly and cautiously when rising and walking. B. Monitor intake and output every 8 hours. C. Ensure the client knows to stop baclofen before using other antispasmodics. D. Evaluate muscle strength every 4 hours.

Correct Answer is A

Explanation

Choice A rationale: Baclofen is a muscle relaxant used to reduce muscle spasticity in conditions such as multiple sclerosis. One of the common side effects of baclofen is dizziness or orthostatic hypotension, which can increase the risk of falls. Therefore, the nurse should advise the client to move slowly and cautiously when rising and walking to prevent falls and injury.

Choice B rationale: Monitoring intake and output every 8 hours is not directly related to the administration of baclofen.

Choice C rationale: Ensuring the client knows to stop baclofen before using other antispasmodics is not the correct intervention. Baclofen should not be abruptly discontinued without medical advice, and its use should be discussed with the healthcare provider.

Choice D rationale: Evaluating muscle strength every 4 hours may be part of the client's overall care plan, but it is not directly related to the administration of baclofen. Muscle strength evaluation is more pertinent for assessing the progression of multiple sclerosis and its effects on muscle function.

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A client in the surgical recovery area asks the nurse to bring the largest possible dose of pain medication available. Which action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse is administering the muscle relaxant baclofen by mouth (PO) to a client diagnosed with multiple sclerosis. Which intervention should the nurse implement?

Correct Answer is A

Explanation

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