Prior to administering pain medication to an adult postoperative client, what information should the practical nurse (PN) obtain? (Select all that apply.)
Height and weight of client prior to admission
Client's pain rating on a scale of 1 to 10
Time of last administration of pain medication
Effectiveness of last pain medication administered
History of pain medication use during the past year
Correct Answer : B,C,D
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Tape the tube to the child's cheek. Rationale: Taping the tube to the child's cheek is not the recommended method for securing a gastrostomy enteral tube. It can cause discomfort and skin irritation for the child. Proper securing methods involve using specialized tube holders or dressings designed for this purpose.
Choice B rationale:
Apply water-soluble lubricant to the site. Rationale: Applying a water-soluble lubricant to the site is not a standard practice for gastrostomy tube care. It is essential to keep the site clean and dry to prevent infection. Lubricants are not typically used in this context.
Choice C rationale:
Attach an extension tube to the site's opening prior to use. Rationale: This is the correct action. Before using the gastrostomy tube, it is essential to attach an extension tube to the site's opening to facilitate feeding or medication administration. This extension tube allows for the connection of feeding syringes or other equipment.
Choice D rationale:
Apply a skin barrier protectant to the site. Rationale: Applying a skin barrier protectant is not typically required for gastrostomy tube care. The primary focus should be on maintaining the cleanliness and integrity of the site to prevent complications such as infection or skin irritation.
Correct Answer is B
Explanation
Choice A rationale:
Placing a pulse oximeter on the client's finger to assess oxygen saturation is important, but in this scenario, establishing a patent airway takes priority. The client's cyanosis and shallow respirations indicate a severe respiratory distress, and the nurse should first ensure the client's ability to breathe before assessing oxygen levels.
Choice B rationale:
Establishing a patent airway is the priority action because the client's shallow respirations and cyanosis indicate a compromised airway and inadequate oxygenation. Ensuring a clear airway is crucial for the client's survival.
Choice C rationale:
Checking the client's pulse rate is an important assessment but should not take precedence over addressing the airway and breathing issues. The client's respiratory distress is a more immediate concern.
Choice D rationale:
Administering oxygen is an appropriate intervention, but it should not be done before ensuring a patent airway. The nurse must prioritize actions to address the most critical issue first.
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