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 D

Explanation

ESR is a laboratory test that measures the rate at which red blood cells settle in a vertical tube of blood over a specific period of time. An elevated ESR is a nonspecific indicator of inflammation in the body, including infections. In the presence of an infection, the body releases certain substances that can increase the rate at which red blood cells settle, leading to an elevated ESR.

Decreased platelet count is not typically associated with infection. Low platelet count, known as thrombocytopenia, can be caused by various factors such as certain medications, autoimmune disorders, or bone marrow disorders. Infection may cause other changes in blood counts, but decreased platelets are not a direct indicator of infection.

Decreased hemoglobin levels, known as anemia, can be caused by various factors such as nutritional deficiencies, chronic diseases, or blood loss. While some infections can lead to anemia indirectly, decreased hemoglobin is not a specific indicator of infection.

Increased iron levels, known as hyperferritinemia, can occur in various conditions, including infections, but it is not a direct indicator of infection. It is important to assess the overall clinical picture and other laboratory findings to determine the cause of increased iron levels.

A. Apply light pressure to the inner canthus just after instilling the eye drops B. Wipe the eye from the inner to the outer canthus with a sterile saline-moistened coton ball C. Administer the medication drops directly into the lower conjunctival sac of each eye D. Wait 5 min after instillation before instilling the drops in the other eye E. None F. None

Correct Answer is A

Explanation

Answer: A. Apply light pressure to the inner canthus just after instilling the eye drops.

Rationale:

A) Apply light pressure to the inner canthus just after instilling the eye drops.
Applying pressure to the inner canthus (the corner of the eye nearest the nose) helps occlude the nasolacrimal duct. This action reduces the systemic absorption of the medication by preventing it from draining into the nasal passages and subsequently into the systemic circulation, thus enhancing the local effect of the eye drops.

B) Wipe the eye from the inner to the outer canthus with a sterile saline-moistened cotton ball.
While this action may help remove excess medication or discharge, it does not minimize systemic absorption. Instead, wiping the eye could inadvertently spread the medication to other areas, increasing the chance of absorption rather than reducing it.

C) Administer the medication drops directly into the lower conjunctival sac of each eye.
While placing drops in the lower conjunctival sac is a standard practice for delivering ophthalmic medications, it does not directly influence systemic absorption. The main goal is to ensure adequate dosing in the eye, but systemic absorption can still occur if the drops drain into the nasolacrimal duct.

D) Wait 5 min after instillation before instilling the drops in the other eye.
Waiting between instillations is good practice to prevent dilution of the first dose and to allow for absorption. However, this action does not significantly impact systemic absorption. It focuses more on ensuring that the first dose is effective before administering a second dose.

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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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Correct Answer is D

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Correct Answer is A

Explanation

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