After administering oxycodone to a client one hour ago, the client is reporting severe pain. Which intervention should the nurse implement next?

Reassess the client and the level of pain.

Tell the client the medication needs more time to work.

Ask the UAP to offer a backrub to the client.

Encourage the client to focus on taking deep breaths.

Answer and Explanation

The Correct Answer is A

Choice A: Reassess the client and the level of pain is the correct intervention because it helps the nurse evaluate the effectiveness of the medication and plan further actions. The nurse should use a valid and reliable pain scale and check for any signs of adverse effects or complications.
Choice B: Tell the client the medication needs more time to work is not a correct intervention because it may dismiss the client’s pain and delay appropriate treatment. The nurse should acknowledge the client’s pain and explain the expected onset and duration of the medication.
Choice C: Ask the UAP to offer a backrub to the client is not a correct intervention because it may not be sufficient or appropriate for the client’s pain. The nurse should assess the client’s pain before delegating any nonpharmacological interventions to the UAP.
Choice D: Encourage the client to focus on taking deep breaths is not a correct intervention because it may not be effective or feasible for the client’s pain. The nurse should assess the client’s pain and offer other complementary therapies that are suitable and acceptable for the client.

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Correct Answer is A

Explanation

Choice A Reason: This is correct because it reflects a measurable and realistic goal that addresses the client's problem of activity intolerance related to pain. Ambulation promotes circulation, prevents complications, and enhances recovery.

Choice B Reason: This is incorrect because it does not address the problem of activity intolerance related to pain. Avoiding pain-causing activity may lead to immobility and further complications.

Choice C Reason: This is incorrect because it does not address the problem of activity intolerance related to pain. Incision healing is an expected outcome of wound care, not activity.

Choice D Reason: This is incorrect because it does not address the problem of activity intolerance related to pain. Taking analgesics as prescribed may help relieve pain, but it does not promote activity.

A. Decrease the flow rate to 1 L/minute. B. Place padding around the cannula tubing. C. Apply lubricant to the cannula tubing. D. Discontinue the use of the nasal cannula.

Correct Answer is B

Explanation

Choice A Reason: This is incorrect because decreasing the flow rate to 1 L/minute can compromise the client's oxygenation and worsen hypoxia. The client's oxygen saturation level is below the normal range of 95% to 100%.

Choice B Reason: This is correct because placing padding around the cannula tubing can prevent pressure ulcers and skin breakdown caused by friction and irritation from the tubing.

Choice C Reason: This is incorrect because applying lubricant to the cannula tubing can increase the risk of infection and inflammation of the nasal mucosa. Lubricant should be applied sparingly to the nares only if needed.

Choice D Reason: This is incorrect because discontinuing the use of the nasal cannula can endanger the client's life and cause respiratory failure. The client needs supplemental oxygen to maintain adequate oxygenation.

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After administering oxycodone to a client one hour ago, the client is reporting severe pain. Which intervention should the nurse implement next?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse observes that there are reddened areas on the cheekbones of a client receiving oxygen per nasal cannula at 3 L/minute, and the client's oxygen saturation level is 92%. Which intervention would the nurse implement?

Correct Answer is B

Explanation

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