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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Immunocompromised individuals have a weakened immune system, which makes them more susceptible to infections. Soiled linens, when placed on the floor, can potentially harbor pathogens and become a source of contamination. It is essential to handle soiled linens properly by placing them in designated containers or bags to prevent the spread of infectious agents.

Uncapped sharps put in a puncture-resistant container: This is the correct practice for disposing of sharps, such as needles or lancets. Uncapped sharps should always be placed in puncture-resistant containers to prevent accidental injuries and potential transmission of infections.

Dampened cloths used for dusting the area: Dampened cloths for dusting can help minimize the dispersal of dust and allergens, but it does not necessarily pose a significant risk of infection.

However, it is important to ensure that the dampened cloths are properly cleaned and sanitized to prevent the growth and spread of microorganisms.

Waste containers lined with single bags: Waste containers lined with single bags are a common practice for proper waste management and disposal. While it is important to maintain good waste management practices to prevent the spread of infections, the use of single bags alone does not significantly affect the risk of infection for immunocompromised clients.

A. Check the client's heart rate on the oximeter B. Compare the result with the baseline reading C. Decrease the amount of oxygen administered D. Perform another reading while the client ambulates E. None F. None

Correct Answer is B

Explanation

Answer: B. Compare the result with the baseline reading

Rationale:

A. Check the client's heart rate on the oximeter:
Although checking the heart rate may provide context for assessing the client's overall status, it does not address the primary concern of the low oxygen saturation. Understanding the client's baseline saturation level takes priority to guide further actions effectively.

B. Compare the result with the baseline reading:
Comparing the reading with the client's baseline is essential. For clients with chronic respiratory conditions, baseline oxygen levels may naturally be lower. Identifying if this 88% saturation is typical or unusual for the client helps determine the need for further intervention or adjustment.

C. Decrease the amount of oxygen administered:
Reducing oxygen flow when the saturation is low is contraindicated, as it could worsen hypoxia. Instead, increasing oxygen may be warranted if the reading remains below the baseline after further assessment.

D. Perform another reading while the client ambulates:
Repeating the reading during ambulation may worsen hypoxia and is not ideal without understanding baseline oxygenation at rest. Re-evaluation at rest or in a different position may be more appropriate for accurate assessment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care to a client who is immunocompromised. Which of the following should the nurse identify as a possible source of infection?

Correct Answer is A

Explanation

A nurse has obtained a client's oxygen saturation measurement of 88% on 2 liters of oxygen via nasal cannula. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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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?