A nurse is caring for a client who received pain medication 1 hr ago and reports pain as 8 on a scale of 0 to 10. Which of the following actions should the nurse take first?
Document the finding in the client's medical record.
Re-evaluate the client's pain status in 1 hr.
Ask the client what has helped relieve their pain in the past.
Obtain a prescription for additional pain medication.
The Correct Answer is C
Rationale:
A. Documenting the pain is important but does not address the client’s immediate need for pain relief.
B. Waiting to re-evaluate in 1 hour delays intervention and does not prioritize the client’s current high pain level.
C. Asking the client what has helped relieve their pain in the past allows the nurse to assess effective interventions and tailor immediate pain management, making this the first action.
D. Obtaining a prescription may be necessary, but the nurse should first assess the client’s response to previous interventions and preferences before taking further steps.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Documenting the pain is important but does not address the client’s immediate need for pain relief.
B. Waiting to re-evaluate in 1 hour delays intervention and does not prioritize the client’s current high pain level.
C. Asking the client what has helped relieve their pain in the past allows the nurse to assess effective interventions and tailor immediate pain management, making this the first action.
D. Obtaining a prescription may be necessary, but the nurse should first assess the client’s response to previous interventions and preferences before taking further steps.
Correct Answer is C
Explanation
Rationale:
A. Contrast dye is used in imaging studies such as CT scans, not pulmonary function tests.
B. Running on a treadmill is part of a cardiac stress test, not a pulmonary function test.
C. A nose clip may be used during pulmonary function testing to ensure that all breathing occurs through the mouth for accurate measurement.
D. Insertion of a tube into the airway refers to procedures such as bronchoscopy or intubation, not a pulmonary function test.
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