Two clients ring their call lights simultaneously requesting pain medication. Which action should the nurse implement first?

Determine when each client last received pain medication.

Evaluate both clients' pain using a standardized pain scale.

Provide nonpharmacologic pain management interventions.

Prepare both clients' medication and take to them at once.

Answer and Explanation

The Correct Answer is B

A. Determine when each client last received pain medication is an important step in managing pain, but it does not address the immediate need to evaluate the severity of the clients' pain. Knowing when they last received pain medication can help with medication timing but should follow a thorough assessment.

B. Evaluate both clients' pain using a standardized pain scale is the most appropriate first action. This allows the nurse to assess the severity of each client’s pain and prioritize which client requires more immediate attention. Pain severity, rather than timing of medication, should guide the nurse's intervention.

C. Provide nonpharmacologic pain management interventions can be helpful, but it does not address the immediate need for assessing and addressing the severity of pain. Nonpharmacologic interventions can be used as an adjunct but should not replace proper assessment and pharmacologic management if necessary.

D. Prepare both clients' medication and take to them at once could lead to a delay in addressing the most severe pain. It is important to assess pain levels first to prioritize care, as one client may require medication sooner than the other.

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Correct Answer is C

Explanation

A. Select upper arm as the injection site is incorrect. While the upper arm can be an appropriate site for an intradermal injection, the most common site for ID injections is the inner forearm. The choice of site depends on the procedure and provider's preferences.

B. Massage the site gently after injection is incorrect. Massaging the site after an intradermal injection can disrupt the injection, causing the medication to be dispersed under the skin rather than remaining in the dermis.

C. Ensure bevel of the needle is pointing up is the correct action. For intradermal injections, the bevel of the needle should be facing upward to ensure that the medication is injected just beneath the skin, creating a visible wheal.

D. Hold the syringe perpendicular to the skin is incorrect. For intradermal injections, the needle should be inserted at a 5-15 degree angle to the skin, not perpendicular.

A. Withhold the medication until the exact dose is available. B. Calculate the dose on hand to match the prescribed dose. C. Report a mismatch of prescribed and available doses. D. Ask the pharmacist if another dose can be dispensed.

Correct Answer is C

Explanation

A. Withhold the medication until the exact dose is available is not the best first action. The nurse should first report the discrepancy to ensure that the prescribed dose is correct and to confirm if the medication should be withheld or adjusted.

B. Calculate the dose on hand to match the prescribed dose is not appropriate. The nurse should not attempt to adjust the medication dose without confirmation from the healthcare provider or pharmacist.

C. Report a mismatch of prescribed and available doses is the correct action. The nurse should immediately report the discrepancy to the pharmacist or healthcare provider to verify the correct dose and prevent potential harm to the client.

D. Ask the pharmacist if another dose can be dispensed is an appropriate follow-up action but is secondary to reporting the mismatch first. The nurse needs to clarify the prescription and dosage before taking further steps.

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Two clients ring their call lights simultaneously requesting pain medication. Which action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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