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.

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Free Nursing Study Resources

Correct Answer is "{\"xRanges\":[56.109375,86.109375],\"yRanges\":[109,139]}"

Explanation

To auscultate for the presence of a carotid artery bruit, the nurse should place the bell of the stethoscope over the carotid artery. Specifically, the nurse should place the bell of the stethoscope lightly on the skin just medial to the sternocleidomastoid muscle at the level of the thyroid cartilage. The carotid artery can be found in the neck, just lateral to the trachea and medial to the sternocleidomastoid muscle.

A. Listen for abnormal sounds. B. Identify S1 and S2 heart sounds. C. Move the stethoscope to the apical site. D. Change to the bell of the stethoscope.

Correct Answer is B

Explanation

A. Listen for abnormal sounds. Before identifying abnormal sounds, it's essential to first establish a baseline by identifying the normal heart sounds (S1 and S2).

B. Identify S1 and S2 heart sounds. This is the correct first step in a systematic assessment of heart sounds. S1 ("lub") corresponds to the closure of the atrioventricular valves (mitral and tricuspid), while S2 ("dub") corresponds to the closure of the semilunar valves (aortic and pulmonic).

C. Move the stethoscope to the apical site. While the apical site is important for auscultating specific heart sounds, it's best to first identify S1 and S2 at the traditional auscultatory areas (aortic, pulmonic, tricuspid, and mitral).

D. Change to the bell of the stethoscope. The bell of the stethoscope is used to listen for lower-pitched sounds, but it's not typically used for identifying S1 and S2 heart sounds, which are higher-pitched.

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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

In auscultating for the presence of a carotid artery bruit, the nurse places the bell of the stethoscope at which location?

Correct Answer is "{\"xRanges\":[56.109375,86.109375],\"yRanges\":[109,139]}"

Explanation

The nurse prepares to begin a systematic assessment of a client's heart sounds. Upon positioning the stethoscope as seen in the picture, which should the nurse do first?

Correct Answer is B

Explanation

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