A client is complaining of severe pain after being medicated one hour ago with hydrocodone with acetaminophen one tablet orally. Which intervention should the nurse implement next?

Tell the client the medication needs more time to work.

Reassess the client and the level of pain.

Ask the unlicensed assistive personnel (UAP) to offer a backrub to the client.

Encourage the client to focus on taking deep breaths.

Answer and Explanation

The Correct Answer is B

A. Telling the client the medication needs more time: While true for some medications, it's important to assess the severity of the pain to determine if further action is needed.

B. Reassessing the client's pain: This is the most crucial step. Reassessment helps determine the effectiveness of the medication and identify any potential issues.

C. Asking UAP to offer a backrub: While comfort measures can be helpful, delegation to an UAP should only occur after a nurse assessment and with clear instructions. In this case, pain management is the priority.

D. Encouraging deep breaths: Distraction techniques can be a complementary approach, but reassessing the pain level is the most urgent step.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Decrease in the appetite. While a decreased appetite can contribute to malnutrition, it is a symptom rather than a definitive indicator of the current nutritional status. Other factors can lead to decreased appetite, and it does not directly quantify malnutrition.

B. Weight of 227 lb (103 kg). This weight alone does not provide information about malnutrition. Without knowing the client's height, the BMI, or body composition, this information is not useful for diagnosing malnutrition.

C. Dry mucosal membranes. Dry mucosal membranes can be a sign of dehydration or other conditions but are not specific to malnutrition.

D. Body mass index (BMI) of 17 kg/m².A BMI of 17 kg/m² is below the normal range (18.5 to 24.9 kg/m²) and directly indicates undernutrition, supporting the diagnosis of malnutrition.

A. Contact social services for a temporary shelter. B. Obtain a hemoglobin and hematocrit level. C. Have the client transported to the hospital. D. Schedule weekly perinatal appointments.

Correct Answer is C

Explanation

A. Contact social services for a temporary shelter. While contacting social services is important for the overall care of a homeless pregnant woman, it is not the immediate priority in the presence of placenta previa and vaginal bleeding.

B. Obtain a hemoglobin and hematocrit level. Assessing hemoglobin and hematocrit levels is important to evaluate the extent of blood loss and anemia, but the priority is to ensure the woman’s and fetus’s immediate safety due to placenta previa.

C. Have the client transported to the hospital. This is the correct action. Placenta previa can cause significant bleeding and requires immediate medical attention, including potential delivery. Transporting the client to the hospital ensures she receives the necessary urgent care.

D. Schedule weekly perinatal appointments. Weekly perinatal appointments are important for ongoing care, but in the context of active bleeding and placenta previa, immediate hospital care is necessary first.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client is complaining of severe pain after being medicated one hour ago with hydrocodone with acetaminophen one tablet orally. Which intervention should the nurse implement next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has been diagnosed with malnutrition. Which finding supports the medical diagnosis?Reference Range: Body Mass Index (BMI) (18.5 to 24.9 kg/m3]

Correct Answer is D

Explanation

A pregnant, homeless woman who has received no prenatal care presents to the clinic in her third trimester because she is having vaginal bleeding, but reports that she is not in pain. Ultrasound reveals a placenta previa. Which action should the nurse implement?

Correct Answer is C

Explanation

The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?

When assessing a client's range of motion, the nurse notes crepitation with movement of the left knee. Which information in the client's history is most likely related to this finding?

While-interviewing an elderly client, the nurse observes that the client's hands tremble uncontrollably while reaching for a glass of water. How should the nurse document this finding?

A client reports episodes of syncope. Which assessment finding should the nurse anticipate?

The school nurse is interviewing an adolescent who wants to go home from school because of "back pain." Which question should the nurse ask first?

A six-year-old girl is being admitted to the hospital for repair of an umbilical hernia. Which information, collected by the admitting nurse, is particularly helpful in planning care for this child?