A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first?
Determine the location of the pain.
Administer the medication.
Reposition the client.
Review the effects of the pain medication.
The Correct Answer is A
A. Determining the location of the pain is the first step in assessing and managing a client's pain. It helps the nurse gather important information about the nature and potential causes of the pain.
B. Administering the medication may be necessary, but it should come after the nurse has assessed the location and characteristics of the pain to ensure the correct medication and dosage are given.
C. Repositioning the client can be important for comfort and pain relief, but it should come after the nurse has assessed the location of the pain to determine the best position for the client.
D. Reviewing the effects of the pain medication is important, but it should come after the nurse has administered the medication. It is essential to first address the client's request for pain relief by assessing the pain location and administering the appropriate
medication.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This statement is incorrect. While HIPAA allows for certain disclosures to family members, it is important to follow specific guidelines and obtain appropriate consent or authorization from the client when sharing their health information. There are also circumstances where a client may request that information be withheld from certain family members.
B. This statement is correct. HIPAA is a federal law that establishes privacy standards for protected health information.
C. This statement is correct. A client's address is considered personally identifiable information under HIPAA.
D. The statement appears to be cut off. However, it is important to note that HIPAA does indeed establish regulations for protecting individually identifiable health information in various forms, including verbal, electronic, and written.
Correct Answer is A
Explanation
A. Observing the client's respiratory status is the priority action because a decreased level of consciousness can potentially lead to compromised airway and respiratory function. It's crucial to monitor for signs of respiratory distress or compromise, such as changes in respiratory rate, depth, and effort.
B. Monitoring intake and output every 8 hr is an important nursing responsibility, but it is not the top priority when the client's respiratory status is in question.
C. Elevating the head of the client's bed 30° to 45° is a standard practice to prevent aspiration and promote optimal digestion during enteral feedings. While important, it is not the immediate priority in this situation.
D. Checking residual volume every 4 to 6 hr is a part of enteral feeding management, but it is not the priority when the client's respiratory status is a concern.
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