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.
Tell the client the medication needs more time to work.
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 A
Explanation
To assess the quality of the client’s pain, the nurse should ask the client to describe the pain.
This will help the nurse to understand the characteristics of the pain and how it is affecting the client.
Choice B is incorrect because providing a numeric pain scale only assesses the intensity of the pain, not its quality.
Choice C is incorrect because identifying effective pain relief measures does not assess the quality of the pain.
Choice D is incorrect because observing body language and movement only provides indirect information about the quality of the pain.
Correct Answer is A
Explanation
Charting by exception means that the nurse only documents findings that deviate from the established norm or expected outcome.
In this case, the nurse should document the assessment that is not within normal limits, which is “Basilar lung sounds that are diminished in the left lung.”
Choice B is not the answer because contraction of the left pupil when light shines in the right eye is a normal finding known as consensual pupillary response.
Choice C is not the answer because capillary refill of 2 seconds in the lower right foot is a normal finding.
Choice D is not the answer because active bowel sounds in the lower right quadrant are a normal finding.
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