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 fluid volume deficit is a life-threatening condition that can result from diarrhea and fecal incontinence. The nurse should monitor the client's fluid intake and output, electrolytes, weight, urine specific gravity, and skin turgor.

Choice B Reason: This is incorrect because bowel incontinence is a significant problem that can affect the client's dignity, comfort, and skin integrity, but it is not as urgent as fluid volume deficit. The nurse should implement a bowel management program and provide appropriate hygiene and skin care.

Choice C Reason: This is incorrect because caregiver role strain is a potential problem that can affect the parent's well-being and ability to provide care, but it is not as critical as fluid volume deficit. The nurse should assess the parent's coping skills, support system, and respite needs.

Choice D Reason: This is incorrect because impaired bed mobility is a chronic problem that can affect the client's functional status and quality of life, but it is not as serious as fluid volume deficit. The nurse should assist the client with positioning, turning, transferring, and exercising.

A. Contact the healthcare provider about the frequency of pain medication. B. Encourage the client to allow more time for the medication to work. C. Review the medical record for additional pain medication prescriptions. D. Administer an additional dose of morphine sulfate 0.2 mg intravenously.

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because contacting the healthcare provider about the frequency of pain medication is a dependent intervention that requires an order from the provider. The nurse should first use independent interventions such as reviewing available prescriptions or providing non-pharmacological measures.

Choice B Reason: This is incorrect because encouraging the client to allow more time for the medication to work can imply that the nurse does not believe or validate the client's report of pain. It also can delay effective pain relief and increase suffering.

Choice C Reason: This is correct because reviewing the medical record for additional pain medication prescriptions can help identify alternative or adjunctive options for pain management, such as breakthrough doses, rescue doses, or non-opioid analgesics.

Choice D Reason: This is incorrect because administering an additional dose of morphine sulfate 0.2 mg intravenously can cause overdose, respiratory depression, or addiction. The nurse should follow the prescribed dosage, route, and interval of administration and monitor for adverse effects.

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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

Naxlex Comprehensive Predictor Exams

The nurse identifies several nursing problems for a client with paraplegia who has been having fecal incontinence and diarrhea. The client's parent is the primary caregiver. In planning care, the nurse should determine which problem is the highest priority?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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