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 B

Explanation

The nurse should include increased cardiac output as an expected eﬀect of digoxin when reinforcing teaching with the client. Digoxin is a positive inotropic medication that strengthens the force of contraction of the heart, resulting in increased cardiac output.

Option a, increased heart rate, is not an expected eﬀect of digoxin. Digoxin may actually decrease heart rate by exerting a negative chronotropic eﬀect.

Option c, decreased urinary output, is not an expected eﬀect of digoxin. In fact, digoxin does not directly aﬀect urinary output.

Option d, decreased potassium level, is not an expected eﬀect of digoxin. However, digoxin can increase the risk of hypokalemia, so it is important to monitor the client's potassium levels while on the medication.

A. Limit ﬂuid intake during the evening B. Perform passive range-of-motion exercises. C. Apply cold compresses to painful areas. D. Provide a low-protein diet

Correct Answer is B

Explanation

b. Perform passive range-of-motion exercises.

During a vaso-occlusive crisis in sickle-cell disease, blood ﬂow to certain areas of the body may be restricted, leading to pain and tissue damage. Passive range-of-motion exercises can help promote blood circulation and prevent joint stiﬀness and further complications. These exercises involve gently moving the child's joints through their full range of motion without active participation from the child.

Explanation for the other options:

a. Limit ﬂuid intake during the evening: Fluid intake is important in sickle-cell disease to prevent dehydration and maintain adequate blood ﬂow. Restricting ﬂuid intake during a vaso-occlusive crisis can further contribute to dehydration and may worsen the crisis. It is important to encourage ﬂuid intake unless otherwise instructed by the healthcare provider.

c. Apply cold compresses to painful areas: Cold compresses are not recommended during a vaso-occlusive crisis in sickle-cell disease. Cold temperatures can cause vasoconstriction and further worsen the blood ﬂow to aﬀected areas, leading to increased pain and tissue damage. Warm compresses or warm packs may be used to promote vasodilation and provide pain relief.

d. Provide a low-protein diet: A low-protein diet is not specifically indicated in the plan of care for a vaso- occlusive crisis in sickle-cell disease. Adequate protein intake is important for overall nutritional needs and tissue repair. The focus of nutritional management in sickle-cell disease is usually on a well-balanced diet that includes adequate hydration and appropriate nutrient intake.

In summary, performing passive range-of-motion exercises is an appropriate intervention to include in the

plan of care for a school-age child experiencing a vaso-occlusive crisis in sickle-cell disease.

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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

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A nurse is contributing to the plan of care for a school-age child who has sickle-cell disease and is experiencing a vaso-occlusive crisis. Which of the following should the nurse recommend to include in the plan of care?

Correct Answer is B

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