A nurse and an assistive personnel (AP) are caring for a client who requests a PRN pain medication. After the nurse administers the medication, which of the following tasks should the nurse assign to the AP?

Document the client's respiratory rate in 1 hr.

Monitor the client for an allergic reaction for 30 min.

Check the client's response to the medication in 1 hr.

Evaluate the client for therapeutic effects in 30 min.

Answer and Explanation

The Correct Answer is A

A.   Documenting the client's respiratory rate in 1 hour is within the scope of practice for an assistive personnel (AP) and does not require nursing judgment or assessment.
B.   Monitoring the client for an allergic reaction for 30 minutes requires nursing judgment and assessment skills to recognize signs and symptoms of allergic reactions.
C.   Checking the client's response to the medication in 1 hour requires nursing judgment and assessment skills to evaluate pain relief and any adverse effects.
D.   Evaluating the client for therapeutic effects in 30 minutes requires nursing judgment and assessment skills to determine the effectiveness of the pain medication.

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Correct Answer is D

Explanation

A. A warm extremity is not typically associated with compartment syndrome. Compartment syndrome may present with coolness due to compromised circulation.

B. Moderate pain on the ankle may be present in compartment syndrome due to increased pressure within the compartment, but it is not a specific manifestation.
C. Blanch time of 2 seconds in the toenail beds indicates normal capillary refill, which is not consistent with compartment syndrome. In compartment syndrome, capillary refill may be delayed.
D. Palpation of a weak or absent dorsalis pedis pulse is a concerning finding indicative of compromised circulation, a hallmark sign of compartment syndrome.

A. "The machine is programmed to prevent you from administering more than a safe dose." B. "During medication administration, you will not be able to move your legs freely." C. "This method of pain control will shorten the second stage of labor." D. "This type of anesthesia commonly causes a postpartum headache."

Correct Answer is B

Explanation

- Choice A Rationale: The epidural PCA (patient-controlled analgesia) is designed with safety mechanisms to ensure that the patient cannot administer a dose that exceeds the prescribed safe limit. This is crucial to prevent potential overdose and complications associated with high doses of analgesics.
- Choice B Rationale: While it is true that some patients may experience reduced mobility in their legs during epidural analgesia, this is not an absolute and can vary based on the dosage and individual response. Therefore, it is not a guaranteed effect and should not be presented as such.
- Choice C Rationale: There is no conclusive evidence to suggest that epidural pain control methods shorten the second stage of labor. In fact, some studies indicate that it may actually prolong it. The primary purpose of epidural PCA is pain management, not altering the labor process timeline.
- Choice D Rationale: Postpartum headaches can be a side effect of epidural anesthesia, but they are not common to all cases. It is associated with a complication known as a post-dural puncture headache, which occurs in a minority of cases. Hence, it should not be stated as a common outcome.

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A nurse and an assistive personnel (AP) are caring for a client who requests a PRN pain medication. After the nurse administers the medication, which of the following tasks should the nurse assign to the AP?

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Naxlex Comprehensive Predictor Exams

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