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 beginning with questions that are less sensitive in nature can help establish rapport and trust with the client, and make the client more comfortable and willing to disclose personal information.

Choice B Reason: This is incorrect because asking questions in a vague, non-specific format can confuse the client and lead to inaccurate or incomplete data. The nurse should ask clear, direct, and open-ended questions that elicit relevant information.

Choice C Reason: This is incorrect because getting the most difficult questions over with first can make the client feel anxious, embarrassed, or defensive, and discourage further communication. The nurse should build up to the more sensitive questions gradually and respectfully.

Choice D Reason: This is incorrect because sharing personal values to put the client at ease can be inappropriate and unprofessional, as it may impose the nurse's beliefs or opinions on the client or create bias or judgment. The nurse should maintain a neutral and objective attitude and respect the client's values.

A. Provide comfort measures such as topical warm application and tactile massage. B. Assist the client to ambulate as much as possible during waking hours. C. Determine client's subjective measure of pain using a numerical pain scale. D. Encourage increased fluid intake and measure urinary output every 8 hours. E. Implement a 24-hour schedule of routine administration of prescribed analgesic.

Correct Answer is ["A","C","E"]

Explanation

Choice A Reason: This is correct because providing comfort measures such as topical warm application and tactile massage can help reduce pain perception and promote relaxation by stimulating non-painful sensory receptors.

Choice B Reason: This is incorrect because assisting the client to ambulate as much as possible during waking hours can increase pain intensity and fatigue by aggravating inflamed or injured tissues. The nurse should encourage moderate physical activity within the client's tolerance level.

Choice C Reason: This is correct because determining client's subjective measure of pain using a numerical pain scale can help assess pain severity and effectiveness of pain management interventions. Pain is a subjective experience that varies among individuals.

Choice D Reason: This is incorrect because encouraging increased fluid intake and measuring urinary output every 8 hours are not directly related to pain management. These interventions are more relevant for clients with fluid imbalance or renal impairment.

Choice E Reason: This is correct because implementing a 24-hour schedule of routine administration of prescribed analgesic can help maintain a steady level of analgesia and prevent breakthrough pain. Chronic pain requires continuous treatment rather than on-demand administration.

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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?

Nursing Test Bank

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