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 B

Explanation

A. Dons sterile gloves when caring for clients with HIV is incorrect. HIV is transmitted through specific body fluids such as blood, semen, and vaginal fluids, but sterile gloves are not required for routine care unless there is a risk of exposure to these fluids. Standard precautions are used for all clients, regardless of their diagnosis.

B. Uses sterile gloves when handling body fluids is correct. Sterile gloves are used in situations where there is a high risk of contamination, such as when handling body fluids that may contain infectious agents, or during invasive procedures.

C. Keeps a pair of gloves in uniform pocket is incorrect. Gloves should not be stored in pockets as this may compromise their sterility or cleanliness. Gloves should be stored in a clean, dry place.

D. Puts on new gloves when entering a client's room is incorrect. Gloves should be worn when necessary, such as when there is a risk of contact with body fluids or contaminated surfaces. They should not be put on automatically without assessing the situation.

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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