Aspirin 81 mg at 0900 daily is prescribed for an adult client. At 0800 the client asks for something for low back pain, but does not have any PRN analgesics prescribed. Which action is best for the nurse to take?
Wait until 0830 and administer the aspirin.
Obtain a prescription for a PRN analgesic.
Assess the client's prothrombin time (PT)/international normalized ration (INR).
Administer the prescribed daily aspirin now.
The Correct Answer is B
Choice A rationale: Waiting until 0830 and administering the aspirin would not address the client's immediate need for pain relief.
Choice B rationale: Obtaining a prescription for a PRN analgesic is the most appropriate action to provide the client with effective pain relief.
Choice C rationale: Assessing the client's prothrombin time (PT)/international normalized ratio (INR) is not necessary in this context and does not address the immediate pain concern.
Choice D rationale: Administering the prescribed daily aspirin now would not address the client’s lower back pain at the moment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: While a history of vomiting at home for 3 days prior to surgery may be relevant, the information provided by the PACU nurse already includes the time of the last administration of nausea medications, making this option less critical at this moment.
Choice B rationale: Providing information about the abdomen, bowel sounds, and the absence of bleeding on the dressing is essential for assessing the postoperative condition of the client. It gives the receiving nurse a comprehensive overview of the client's immediate status following surgery.
Choice C rationale: Refusal to take ice chips for complaints of dry mouth is relevant to the client's comfort and hydration but may not be as critical as assessing surgical outcomes and complications.
Choice D rationale: Information about peripheral pulses and the range of motion of both legs is important but may be more pertinent to the neurological and circulatory assessment rather than immediate postoperative concerns. The surgical site and abdominal assessment are more directly related to the recent laparotomy.
Correct Answer is C
Explanation
Choice A rationale: The initial administration of the opioid analgesic is appropriate as long as the nurse adheres to the prescription made.
Choice B rationale: Administering naloxone via IV is an appropriate intervention to reverse the effects of opioid toxicity. It is not the focus of counseling in this scenario.
Choice C rationale: The nurse should have notified the healthcare provider as soon as the client's respiratory rate decreased to 6 breaths/minute, which is a sign of respiratory depression caused by the opioid analgesic. The nurse should not have waited until the client's respiratory rate decreased to 4 breaths/minute, which is a life-threatening condition that requires immediate intervention.
Choice D rationale: Documentation of the client's respiratory rate is essential for monitoring, and there is no indication that the documentation was inappropriate.
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