The primary health care provider instructs the nurse to obtain the patient’s pain level every four hours. Which actions by the nurse help facilitate the pain assessment? Select all that apply.
Use a standard pain assessment tool
Increase features of the scale, such as font size
Repeat instructions and questions more than once D. Ask about present level of pain rather than pain history
Ask about present level of pain rather than pain history
Allow ample time for the patient to respond (Source: https://quizlet.com/129952120/pain-assessment-hesi-flash-cards/).
Correct Answer : A,B,C,E
The correct answer is choice A, B, C and E. These actions by the nurse help facilitate the pain assessment by using a consistent and clear method to measure the patient’s pain level, enhancing the visibility and understanding of the scale, repeating the information for clarity and accuracy, and giving the patient enough time to respond without rushing or interrupting.
Choice D is wrong because asking about the present level of pain rather than the pain history is more relevant for pain management, not the pain assessment. The pain history provides valuable information about the onset, duration, frequency, quality, intensity, location, and aggravating or relieving factors of the pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
The correct answer is choice A, B, and C. These are all liver enzymes that can indicate hepatotoxicity (liver damage) from acetaminophen overdose.
The normal ranges for these enzymes are:
• AST: 10 to 40 U/L
• ALT: 7 to 56 U/L
• ALP: 45 to 115 U/L
Choice D and E are wrong because they are indicators of renal function, not liver function.
The normal ranges for these values are:
• BUN: 7 to 20 mg/dL
• Creatinine: 0.6 to 1.2 mg/dL
Correct Answer is B
Explanation
The correct answer is choice B. Check the client’s allergy history.
This is because morphine sulfate is a medication that can cause severe allergic reactions in some people, such as anaphylaxis, which can be life-threatening.
Therefore, the nurse should always check the client’s allergy history before administering any medication, especially opioids.
Choice A is wrong because assessing the client’s respiratory rate is not the first action the nurse should take.
Although morphine sulfate can cause respiratory depression, which is a serious side effect that needs to be monitored, the nurse should first ensure that the client is not allergic to the medication.
Choice C is wrong because reviewing the client’s medication record is not the first action the nurse should take.
Although morphine sulfate can interact with other medications, such as sedatives, antidepressants, or alcohol, which can increase the risk of respiratory depression or overdose, the nurse should first ensure that the client is not allergic to the medication.
Choice D is wrong because verifying the dosage with another nurse is not the first action the nurse should take.
Although morphine sulfate is a high-alert medication that requires double-checking to prevent medication errors, the nurse should first ensure that the client is not allergic to the medication.
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