A client is requesting medicine for pain 30 minutes after receiving morphine sulfate 5 mg intravenously. Which intervention should the nurse implement next?

Ask the UAP to offer a backrub to the client.

Reassess the client and the level of pain.

Tell the client the medication needs more time to work.

Encourage the client to focus on taking deep breaths.

Answer and Explanation

The Correct Answer is B

A. Asking a UAP to offer a backrub is not appropriate if the pain assessment indicates that the current pain management strategy is insufficient. The nurse needs to reassess the pain to determine the effectiveness of the medication and whether additional interventions are needed.
B. Reassessing the client and the level of pain is essential to evaluate the effectiveness of the morphine sulfate administered and to guide further pain management decisions. This step is crucial for understanding the client's current pain status and determining the next steps in pain management.
C. Telling the client that the medication needs more time to work does not address the client's immediate concern or pain relief. Reassessing pain and potentially adjusting the treatment plan is more appropriate.
D. Encouraging deep breathing may help with pain management but does not address the need for further assessment of the pain level or potential adjustment in medication. Reassessing pain is the priority.

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Correct Answer is D

Explanation

A. Temperature is important but does not directly address the immediate concern of cyanosis, which suggests possible issues with oxygenation.
B. Blood pressure is also important, but in the context of cyanosis, assessing the respiratory status is more directly related to identifying the cause of decreased oxygenation.
C. Heart rate is crucial for assessing circulatory status, but cyanosis often indicates a problem with oxygenation, making it less immediately relevant compared to respiratory assessment.
D. Respiratory rate should be assessed first as cyanosis can indicate impaired oxygenation, which is often due to respiratory issues. Evaluating the respiratory rate helps determine if there is a problem with breathing or gas exchange that needs immediate attention.

A. Reduce the amount of pressure being applied on the top of the foot. B. Palpate the site on the inner side of the ankle below the medial malleolus. C. Obtain a doppler stethoscope to auscultate the pulse at the same site. D. Document in the nurses' notes that the dorsalis pedis pulse is not palpable.

Correct Answer is A

Explanation

A. Reducing the amount of pressure applied is the appropriate next step because excessive pressure can occlude the pulse, making it difficult to feel. Lightening the pressure may help the nurse detect the pulse.
B. Palpating the posterior tibial pulse (below the medial malleolus) is another option if the dorsalis pedis pulse is not palpable, but it should be attempted only after ensuring that proper technique was used to feel the dorsalis pedis pulse.
C. Using a Doppler stethoscope is a good option if the pulse remains non-palpable after proper technique has been used. However, it is not the immediate next step.
D. Documenting that the dorsalis pedis pulse is not palpable should be done after all appropriate steps, including adjusting the pressure and possibly using a Doppler, have been attempted.

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A client is requesting medicine for pain 30 minutes after receiving morphine sulfate 5 mg intravenously. Which intervention should the nurse implement next?

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Naxlex Comprehensive Predictor Exams

The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?

Correct Answer is D

Explanation

To assess a client's dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes, but does not feel a pulsation. Which action should the nurse take next?

Correct Answer is A

Explanation

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Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.