A nurse is collecting data from a client who is postoperative and received hydromorphone 4 mg PO 15 min ago. The client tells the nurse, "My pain level is still 8 on a 0 to 10 scale." Which of the following actions should the nurse take first?
Contact the provider to prescribe more pain medication for the client.
Teach the client relaxation techniques for the treatment of acute pain.
Document the client's reaction to the administration of medication.
Reevaluate the client's response to the medication in 30 min.
The Correct Answer is D
The first action the nurse should take is to reevaluate the client's response to the medication in 30 min. Hydromorphone has an onset of action of 15 to 30 minutes when taken orally ¹. Therefore, it may take some time for the medication to reach its full effect.
Option a is incorrect because it may not be necessary to contact the provider for more pain medication until after reevaluating the client's response to the medication.
Option b is incorrect because teaching relaxation techniques may not provide immediate relief for acute pain.
Option c is incorrect because documenting the client's reaction to the administration of medication should be done after reevaluating their response to the medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a. "Start the first patch on the seventh day of the menstrual cycle."
Explanation:
The correct answer is a. "Start the first patch on the seventh day of the menstrual cycle."
When providing teaching about a combination contraceptive transdermal patch, it is important to provide accurate and relevant information to ensure its effectiveness and proper use.
Option b is not the correct answer. The contraceptive effect of the transdermal patch does not continue for 6 months following discontinuation. Its effectiveness lasts only as long as the client continues to use it according to the prescribed schedule.
Option c is not the correct answer. The transdermal patch should be applied to a clean, dry area of the skin that is free from cuts, rashes, or irritation. The lower abdomen is not a recommended site for application.
Option d is not the correct answer. While headaches can occur as a side effect of hormonal contraceptives, it is not necessary to expect a headache during the first month. Side effects can vary among individuals, and it is important to monitor and report any concerning symptoms to the healthcare provider.
By instructing the client to start the first patch on the seventh day of the menstrual cycle, the nurse provides specific guidance on when to initiate the contraceptive method. This ensures that the client is starting the patch at an appropriate time in their menstrual cycle, optimizing its effectiveness
Correct Answer is B
Explanation
A nurse collecting data on a client who has swelling of the lower leg should identify that moderate pain on the ankle of the affected extremity is a manifestation of compartment syndrome. Compartment syndrome is a painful condition that occurs when pressure within a muscle compartment increases to dangerous levels.
The other options are not typical symptoms of compartment syndrome.
a) An affected extremity being warm to touchis not a typical symptom of compartment syndrome.
c) A blanch time of 2 seconds in the toenail beds of the affected extremity is not a typical symptom of compartment syndrome.
d) Palpation of a +1 dorsal pedal pulse of the affected extremity is not a typical symptom of
compartment syndrome.
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