The nurse is reviewing the admission assessment of a client with chronic pain. What Intervention(s) should the nurse Include in the client's plan of care? Select all that apply.

Encourage Increased fluid intake and measure urinary output every 8 hours.

Assist the client to ambulate as much as possible during waking hours.

Determine client's subjective measure of pain using a numerical pain scale.

Provide comfort measures such as topical warm application and tactile massage.

Implement a 24 hour schedule of routine administration of prescribed analgesic.

Answer and Explanation

Correct Answer : B,C,D,E

A. Encourage increased fluid intake and measure urinary output every 8 hours:

While hydration and monitoring urinary output are important aspects of overall health care, they are not specifically related to managing chronic pain. Therefore, this intervention may not be directly relevant to addressing the client's pain.

B. Assist the client to ambulate as much as possible during waking hours:

Ambulation helps maintain mobility, prevent complications like muscle atrophy and deep vein thrombosis, and can improve overall well-being. For clients with chronic pain, assisting with ambulation can be beneficial in managing pain and improving quality of life. The goal is to balance activity with the client's pain tolerance and capabilities.

C. Determine client's subjective measure of pain using a numerical pain scale:

Using a numerical pain scale helps assess the intensity of pain and monitor changes over time. It provides valuable information for tailoring pain management strategies to the client's needs and allows for evaluating the effectiveness of interventions.

D. Provide comfort measures such as topical warm application and tactile massage:

Comfort measures such as warm applications and massage can help alleviate pain and promote relaxation. These interventions address the client's comfort and well-being, making them appropriate for inclusion in the plan of care for managing chronic pain.

E. Implement a 24-hour schedule of routine administration of prescribed analgesic:

Establishing a regular schedule of analgesic administration helps maintain consistent pain control and prevents breakthrough pain. This intervention is essential for managing chronic pain effectively and promoting the client's comfort and quality of life.

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Correct Answer is ["1"]

Explanation

To determine how many tablespoons the client should take with each dose, we need to first calculate the dosage in tablespoons based on the concentration of the oral suspension.

Given:

Dextromethorphan oral suspension concentration: 30 mg per 15 mL

To find out how many milliliters the client should take per dose:

The prescribed dose is 30 mg.

So, if 15 mL contains 30 mg, then 1 mL contains:

30 mg / 15 mL = 2 mg/mL

To find out how many milliliters the client should take for the prescribed dose:

30 mg / 2 mg/mL = 15 mL

Now, we know that the prescribed dose is 15 mL. To convert this to tablespoons, we can use the fact that 1 tablespoon (tbsp) is equal to 15 milliliters.

So, the client should take:

15 mL / 15 mL/tbsp = 1 tablespoon

Therefore, the nurse should instruct the client to take 1 tablespoon with each dose.

A. Irrigate the nasogastric tube with water. B. Perform oropharyngeal suctioning. C. Elevate the head of bed 45 degrees. D. Review the advanced directive document.

Correct Answer is C

Explanation

Correct answer: C

A. Irrigate the nasogastric tube with water:

This option is not the best immediate action when a client is choking after vomiting. While irrigating the nasogastric tube with water may help clear the tube itself, it does not directly address the choking episode or potential airway obstruction. The priority in this situation is to ensure the client's airway is clear and maintain their safety.

B. Perform oropharyngeal suctioning:

While suctioning might be used later to clear the airway of secretions, it's not the first-line intervention when someone is actively choking. Suctioning can stimulate the gag reflex and worsen vomiting..

C. Elevate the head of bed 45 degrees:

The primary concern is preventing aspiration (inhaling vomit) which can lead to serious complications. Elevating the head of the bedhelps keep the head and neck in a position that promotes drainage of fluids and reduces the risk of aspiration.

D. Review the advance directive document:

Reviewing the advance directive document is important for understanding the client's wishes regarding their healthcare decisions, but it is not the appropriate action in the immediate management of a choking episode. Ensuring the client's safety and addressing the choking episode take precedence over reviewing documentation.

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The nurse is reviewing the admission assessment of a client with chronic pain. What Intervention(s) should the nurse Include in the client's plan of care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours PO as needed for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)

Correct Answer is ["1"]

Explanation

A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?

Correct Answer is C

Explanation

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