An adolescent hospitalized with sickle cell anemia reports to the nurse of experiencing a pain level of 10 on a 0 to 10 numerical scale. The nurse observes the adolescent on a phone call laughing. Which action should the nurse take?
Introduce non-pharmacologic strategies for pain reduction.
Allow adequate privacy and time for the client's phone call.
Document the concern of incongruent pain rating and behavior.
Administer pain medication per the healthcare provider's orders.
The Correct Answer is B
Choice A: Introducing non-pharmacologic strategies for pain reduction is a valid intervention for managing pain in a client with sickle cell anemia. However, in this scenario, the client's laughter on the phone call may not necessarily indicate that the pain level is accurately reflected by the numerical rating. It is essential to consider the client's overall well-being and pain management plan.
Choice B: Allowing adequate privacy and time for the client's phone call is a considerate and appropriate action. It acknowledges the client's need for communication and emotional support, which can be important in managing pain.
Choice C: Documenting the concern of incongruent pain rating and behavior is a necessary step for the nurse to record the observation. However, it should not be the only action taken in response to the situation.
Choice D: Administering pain medication should be based on a comprehensive assessment of the client's pain and the healthcare provider's orders. While pain medication may be indicated for this client, it should not be administered solely based on the numerical pain rating without further assessment and consideration of the client's overall condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Introducing non-pharmacologic strategies for pain reduction is a valid intervention for managing pain in a client with sickle cell anemia. However, in this scenario, the client's laughter on the phone call may not necessarily indicate that the pain level is accurately reflected by the numerical rating. It is essential to consider the client's overall well-being and pain management plan.
Choice B: Allowing adequate privacy and time for the client's phone call is a considerate and appropriate action. It acknowledges the client's need for communication and emotional support, which can be important in managing pain.
Choice C: Documenting the concern of incongruent pain rating and behavior is a necessary step for the nurse to record the observation. However, it should not be the only action taken in response to the situation.
Choice D: Administering pain medication should be based on a comprehensive assessment of the client's pain and the healthcare provider's orders. While pain medication may be indicated for this client, it should not be administered solely based on the numerical pain rating without further assessment and consideration of the client's overall condition.
Correct Answer is C
Explanation
Choice A: Changing the normal saline to a keep-open rate (KVO) is not appropriate in this situation, as the client has specific fluid orders that need to be followed, and a KVO rate would not provide the prescribed maintenance fluids.
Choice B: Increasing the rate of the present normal saline infusion to 75 drops per minute would not meet the prescription for 0.9% normal saline at 75 ml/hour.
Adjusting the rate this way would require an infusion pump.
Choice C: Leaving the normal saline at the current rate until an infusion pump is available is the most appropriate action. It ensures that the client continues to receive fluids at the ordered rate until the necessary equipment is in place.
Choice D: Switching the saline to Lactated Ringer's solution infusing at 75 drops per minute would not meet the prescribed rate for the normal saline solution. The nurse should follow the specific orders provided.
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