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: this is not an appropriate response because while it may reduce the intake of vitamin K, suddenly changing the client's diet drastically may not be necessary. It is essential for the healthcare provider to make any necessary adjustments to the medication based on the client's diet.

Choice B rationale: Warfarin is an anticoagulant medication that works by inhibiting the formation of blood clots. It interacts with vitamin K, which plays a crucial role in the blood clotting process. Leafy green vegetables are rich in vitamin K, and their consumption can affect the effectiveness of warfarin. The nurse should advise the client to inform her healthcare provider about her vegetarian diet and the regular consumption of leafy green vegetables. The healthcare provider will then be able to adjust the warfarin dosage accordingly to ensure that the client receives the appropriate and consistent level of anticoagulation.

Choice C rationale: while a vegetarian diet can be healthy, the specific concern here is the potential impact of vitamin K-rich foods on warfarin therapy. It's essential to address this potential interaction rather than focusing solely on the overall healthy lifestyle.

Choice D rationale: Consuming large amounts of leafy green vegetables and vitamin K-rich foods may actually reduce the effectiveness of warfarin, leading to a decreased ability to prevent blood clots. Therefore, it is crucial to consult with the healthcare provider to manage the dosage appropriately.

A. Assess the client for side effects of carbamazepine. B. Notify the healthcare provider of the carbamazepine level. C. Administer the carbamazepine as prescribed. D. Withhold this dose of the carbamazepine.

Correct Answer is C

Explanation

a) Assess the client for side effects of carbamazepine:

This option might seem reasonable as monitoring for side effects is essential with any medication, especially one with a narrow therapeutic range like carbamazepine. However, the client's level of 8.4 mcg/L is within the therapeutic range (4 to 12 mcg/mL), so there's no immediate indication that side effects are likely to occur solely based on this level.

b) Notify the healthcare provider of the carbamazepine level:

While it's important to keep the healthcare provider informed about the client's condition, in this case, the carbamazepine level is within the therapeutic range. There's no urgent need to notify the provider unless there are other concerning factors not mentioned in the scenario.

c) Administer the carbamazepine as prescribed:

This is the correct answer. The client's morning carbamazepine level of 8.4 mcg/L falls within the therapeutic range (4 to 12 mcg/mL). Therefore, the evening dose should be administered as prescribed to maintain therapeutic levels and control the client's condition.

d) Withhold this dose of the carbamazepine:

Withholding the dose based solely on the morning carbamazepine level of 8.4 mcg/L, which is within the therapeutic range, would not be appropriate. Withholding the dose without consulting the healthcare provider could potentially lead to suboptimal management of the client's condition.

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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

A female client who is a vegetarian has a new prescription for warfarin. The client states she eats leafy green vegetables every day. How should the nurse respond?

Correct Answer is B

Explanation

Prior to administering the evening dose of carbamazepine, the nurse notes that the client's morning carbamazepine level was 8.4 mcg/L (35.6 mcmol/L). Which action should the nurse take? Carbamazepine level [Reference Range: 4 to 12 mcg/mL or 16.9 to 50.8 mcmol/L]

Correct Answer is C

Explanation

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