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.
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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Related Questions
Correct Answer is D
Explanation
A. The medication should not be kept or stored once it has been removed from its original packaging, especially if it’s not administered. Proper disposal or return to the pharmacy is required.
B. The medication should not be put back in the client’s medication box due to safety and contamination concerns.
C. While controlled substances need careful management, the client’s refusal must be respected, and the medication must be disposed of properly if not administered.
D. Having another nurse witness the disposal of the medication ensures that it is done according to protocols and provides accountability. This practice helps maintain the integrity and safety of medication handling.
Correct Answer is B
Explanation
A. Impaired bed mobility is a concern, especially for an immobile client, but addressing fluid volume deficit takes precedence due to its immediate impact on the client's health.
B. Fluid volume deficit is a critical issue, particularly with diarrhea, which can lead to dehydration and electrolyte imbalances. Ensuring adequate fluid intake and managing fluid balance is essential for preventing complications.
C. Bowel incontinence is a significant issue but managing fluid volume deficit is more urgent to prevent potential complications from dehydration.
D. Caregiver role strain is important, but the immediate priority should be addressing the client’s health needs, such as preventing and managing fluid volume deficit, which can impact overall well-being.
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