A nurse and 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

After the nurse administers a PRN pain medication to a client, the nurse can assign the assistive personnel (AP) to document the client's respiratory rate in 1 hour. This is within the scope of practice of an AP.

The other tasks are not appropriate for an AP to perform.

Monitoring the client for an allergic reaction and evaluating the client for therapeutic eﬀects are both nursing assessments that should be performed by the nurse.

Checking the client's response to the medication is also a nursing assessment that should be performed by the nurse.

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Correct Answer is C

Explanation

Answer: (C) The client is not grimacing

Rationale:

A) The client's blood pressure has been reduced:

While morphine can lower blood pressure due to its vasodilatory effects, a reduction in blood pressure is not necessarily a primary indicator of a therapeutic response to pain relief. It is more important to assess pain relief directly through the client's subjective experience and behavior rather than focusing on vital signs alone.

B) The client exhibits diaphoresis:

Diaphoresis, or sweating, can occur as a side effect of morphine administration but does not indicate that the medication is effectively relieving pain. In fact, diaphoresis might signal an adverse reaction or discomfort rather than a therapeutic effect.

C) The client is not grimacing:

The absence of grimacing suggests that the client's pain has decreased, which is a direct indicator of a therapeutic response to morphine. Observing a reduction in pain-related behaviors, such as grimacing, is a key assessment for determining the effectiveness of pain management in postoperative clients.

D) The client has an elevated heart rate:

An elevated heart rate may be a sign of unresolved pain or a side effect of morphine but is not a clear indicator of pain relief. Effective pain management with morphine typically results in a decrease in sympathetic nervous system responses, such as a high heart rate, rather than an increase.

A. Schedule the medication at meal times. B. Request the family talk to the provider about administering the medication by injection. C. Inform the family that the client has the right not to take the medication. D. Ask the family what foods the client likes.

Correct Answer is C

Explanation

The nurse should inform the family that the client has the right to refuse medication. It is important to

respect the client's autonomy and right to make decisions about their own care.

a) Scheduling the medication at meal times does not address the issue of the client refusing their medication.

b) Requesting that the family talk to the provider about administering the medication by injection may be an option, but it does not address the issue of informed consent.

d) Asking the family what foods the client likes does not address the issue of informed consent and could be seen as a way to deceive the client into taking their medication.

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A nurse and 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?

Nursing Test Bank

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