A nurse is assessing a client who has a heart rate of 40/min. The client is diaphoretic and has chest pain. Which of the following medications should the nurse plan to administer?

Choice A Reason

Determine the time the last dose of pain medication was administered. While it is important to know when the last dose of pain medication was given, assessing the client’s current pain level is a priority. This helps in understanding the severity and nature of the pain, which guides further interventions.

Choice B Reason

Reposition the client to assist with reduction of pain. Repositioning can help alleviate pain, but it should be done after assessing the pain. Without understanding the pain’s characteristics, repositioning might not address the underlying issue effectively.

Choice C Reason

Ask the client to describe the pain and rate it on a scale of 0 to 10. This is the correct first action. Pain assessment is crucial in determining the appropriate intervention. By asking the client to describe and rate their pain, the nurse can tailor the pain management plan to the client’s specific needs.

Choice D Reason

Check the client’s medical record for type of PRN pain medication. Reviewing the medical record for PRN pain medication is important, but it should follow the initial pain assessment. Knowing the pain’s intensity and characteristics will help in deciding whether PRN medication is needed.

Choice A Reason

Apply an ice pack directly to the affected area. This statement is incorrect. Applying ice to a snake bite can cause more harm than good. Ice can restrict blood flow and potentially increase tissue damage. The recommended approach is to keep the bite area still and at or below heart level to slow the spread of venom.

Choice B Reason

Immobilize the affected extremity with a splint. This is the correct intervention. Immobilizing the affected limb helps to slow the spread of venom by reducing movement. Keeping the limb still and using a splint can prevent the venom from circulating more rapidly through the body.

Choice C Reason

Place a tourniquet above and below the affected area. This statement is incorrect. Using a tourniquet is not recommended for snake bites as it can cause severe damage to the affected limb by cutting off blood flow completely. This can lead to tissue death and other complications.

Choice D Reason

Elevate the affected extremity. This statement is incorrect. Elevating the limb can increase the spread of venom. The affected limb should be kept at or below heart level to slow the venom’s spread.