A nurse is caring for a client who is postoperative following arthroscopy and reports a pain level of 6 on a scale of 0 to 10 after receiving ketorolac 1 hr ago.
Which of the following actions should the nurse take?

Tell the client they can have another dose of ketorolac in 3 hr.

Administer oxycodone 5 mg orally.

Give acetaminophen 650 mg rectally.

Document that the client is exhibiting drug-seeking behaviors.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Ketorolac is a non-steroidal anti-inflammatory drug (NSAID) used for pain relief after surgery. However, it’s not typically administered every 3 hours. Overuse can lead to serious side effects.

Choice B rationale:

If the client’s pain level remains high after receiving ketorolac, administering an opioid medication like oxycodone may be appropriate.

Choice C rationale:

While acetaminophen can be used for pain relief, rectal administration is not typically the first choice for postoperative pain management.

Choice D rationale:

It’s inappropriate to label a patient as exhibiting drug-seeking behaviors simply because their reported pain level remains high after medication. Pain is subjective and should be addressed appropriately.

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Correct Answer is B

Explanation

Choice A rationale:

While a tuberculin syringe can be used for insulin administration, it’s not necessary when mixing NPH and regular insulin. Insulin syringes are typically used for this purpose.

Choice B rationale:

Injecting air into each vial before withdrawing insulin helps equalize pressure and makes it easier to draw up the insulin. This should be done before withdrawing any insulin.

Choice C rationale:

Withdrawing NPH insulin first contradicts the standard practice of drawing up insulins. The usual recommendation is to draw up short-acting (regular) insulin before intermediate-acting (NPH) insulin.

Choice D rationale:

Shaking the regular insulin vial is unnecessary and could potentially create bubbles, making it harder to draw up the correct dose of insulin.

A. "Using morphine PCA increases the client's risk of toxicity.” B. "Diarrhea is an adverse effect of morphine PCA.” C. "Check the client's pain level every 8 hours.” D. "Instruct the client's visitors not to operate the PCA pump.”

Correct Answer is D

Explanation

Choice Arationale:

Using PCA does not necessarily increase the client’s risk of toxicity. PCA allows the client to self-administer preset doses of pain medication, which can lead to better pain control with less risk of overdose.

Choice B rationale:

Diarrhea is not a common adverse effect of morphine. Constipation, not diarrhea, is a common side effect due to slowed gastrointestinal motility.

Choice Crationale:

Checking the client’s pain level every 8 hours is not sufficient when using PCA. Pain levels should be assessed more frequently, ideally before and after each administration of the medication. This allows for timely adjustments to the medication regimen if needed.

Choice D rationale:

Instructing the client’s visitors not to operate the PCA pump is crucial. Only the patient should administer doses to prevent overdose.

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A nurse is caring for a client who is postoperative following arthroscopy and reports a pain level of 6 on a scale of 0 to 10 after receiving ketorolac 1 hr ago.Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to mix NPH insulin and regular insulin for administration.Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a newly licensed nurse about monitoring morphine patient-controlled analgesia (PCA). Which of the following information should the nurse include?

Correct Answer is D

Explanation

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A nurse is caring for a client who is postoperative following arthroscopy and reports a pain level of 6 on a scale of 0 to 10 after receiving ketorolac 1 hr ago.
Which of the following actions should the nurse take?