The nurse is providing postoperative care for a client who complains of severe pain after receiving codeine 30 mg orally one hour ago.
Which intervention should the nurse implement next?
Ask the UAP to offer back rubs to the client.
Reassess the client and the level of pain.
Encourage the client to focus on taking deep breaths. D. Tell the client the medication needs more time to work.
Holds the crutch 6 inches (15 cm) to the side.
The Correct Answer is B
The nurse should reassess the client’s pain level and determine if additional interventions are needed to manage the pain.
Choice A is not the answer because while a back rub may provide some temporary relief, it does not address the underlying cause of the pain.
Choice C is not the answer because while deep breathing can help with relaxation, it does not address the underlying cause of the pain.
Choice D is not the answer because telling the client that the medication needs more time to work does not address their current pain level or provide any immediate relief.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
If a nurse observes that a client is using accessory muscles, it indicates an obstruction of the airways, which reduces oxygen saturation.
Accessory muscles help in the act of forced expiration to wash out carbon dioxide and improve oxygen saturation 1.
Therefore, the nurse should obtain the respiratory rate first.
Choice A is not the answer because determining pulse pressure will not provide any significant indication of respiratory distress 1.
Choice C is not the answer because temperature does not provide any significant data about the use of accessory muscles in respiration 1.
Choice D is not the answer because pulse rate does not provide any significant data about the use of accessory muscles in respiration 1.
Correct Answer is B
Explanation
Hyperkalemia is a condition where there is an elevated level of potassium in the blood.
It can occur in patients with renal disease due to the kidneys’ reduced ability to excrete potassium.
Treatment-related side effects, such as certain medications or chemotherapy, can also contribute to hyperkalemia by altering potassium levels in the body1.
Hyperkalemia can lead to life-threatening cardiac conduction disturbances2.
Therefore, it is important for the nurse to determine the apical pulse rate and rhythm.
Choice A is not correct because comparing muscle strength bilaterally is not the most important intervention for a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L).
Choice C is not correct because measuring color and amount of urine is not the most important intervention for a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L).
Choice D is not correct because assessing strength of deep tendon reflexes is not the most important intervention for a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L).
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