The nurse is performing an admission assessment on a stable patient admitted after a motor vehicle accident.
The patient reports having bad pain.
What will the nurse do first?
Attempt to determine what type of pain the patient has.
Request an order for intravenous opioid analgesic.
Administer acetaminophen (Tylenol).
Ask the patient to rate the pain on a scale of 1-10.
The Correct Answer is D
Choice A rationale
Determining the type of pain is secondary to assessing pain severity.
Choice B rationale
Intravenous opioids are strong and should be considered only after evaluating pain severity.
Choice C rationale
Administering acetaminophen without assessing pain severity first is not appropriate.
Choice D rationale
Asking the patient to rate their pain helps gauge severity, guiding further pain management steps.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Itching and rash are not common adverse effects associated with calcium-channel blockers. They are more commonly related to other classes of medications.
Choice B rationale
Hypertension and tachycardia are not typical adverse effects of calcium-channel blockers. These medications are usually prescribed to treat hypertension and can actually cause a reduction in heart rate.
Choice C rationale
Nausea and diarrhea are possible side effects of many medications, but they are not specific adverse effects commonly linked to calcium-channel blockers.
Choice D rationale
Headache and dizziness are common adverse effects of calcium-channel blockers. These medications can cause vasodilation, leading to headaches and a decrease in blood pressure, which may result in dizziness, especially when standing up quickly. .
Correct Answer is B
Explanation
Choice A rationale
Peripheral edema is more commonly associated with right-sided heart failure rather than left-sided. This is because right-sided heart failure leads to systemic venous congestion, causing fluid to accumulate in the peripheral tissues, particularly in the legs and ankles.
Choice B rationale
Pulmonary edema is a major concern in left-sided heart failure due to the inability of the left ventricle to effectively pump blood out to the systemic circulation. This results in blood backing up into the pulmonary veins, leading to fluid accumulation in the lungs.
Choice C rationale
Liver edema, or hepatomegaly, is more typically seen in right-sided heart failure, where the failure of the right ventricle causes blood to back up into the systemic circulation, affecting the liver and other organs.
Choice D rationale
Abdominal edema, or ascites, is also more associated with right-sided heart failure. This condition occurs due to increased pressure in the veins and capillaries, leading to fluid leakage into the abdominal cavity.
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