Nokea
The client is complaining of incisional pain. Which intervention should the nurse implement first?
- A. Administer the pain medication STAT.
- B. Determine when the last pain medication was given.
- C. Assess the client's pulse and blood pressure.
- D. Teach the client distraction techniques to address pain.
Correct Answer: B
Rationale: Determining the last dose ensures safe timing and avoids overdose, the first step in pain management per nursing process.
You may also like to solve these questions
The female nurse realizes she did not administer a medication on time to the client diagnosed with a myocardial infarction. Which action should the nurse implement?
- A. Administer the medication and take no further action.
- B. Notify the director of nurses of the medication error.
- C. Complete a medication error report form.
- D. Report the error to the Peer Review Committee.
Correct Answer: C
Rationale: A medication error requires completing an error report per facility policy to ensure tracking and quality improvement, especially for MI patients.
The employee health nurse is discussing hepatitis B vaccines with new employees. Which statement best describes the proper administration of the hepatitis B vaccine?
- A. The vaccine must be administered once a year.
- B. Two (2) mL of vaccine should be given in each hip.
- C. The vaccine is given in three (3) doses over a six (6)-month time period.
- D. The vaccine is administered intradermally into the deltoid muscle.
Correct Answer: C
Rationale: Hepatitis B vaccine is given in three IM doses (0, 1, 6 months), per CDC guidelines. Annual dosing, split doses, or intradermal routes are incorrect.
The provider has ordered daily high doses of aspirin for a client with rheumatoid arthritis. The nurse instructs the client to discontinue the medication and contact the provider if which of the following symptoms occur?
- A. Infection of the gums
- B. Diarrhea for more than one day
- C. Numbness in the lower extremities
- D. Ringing in the ears
Correct Answer: D
Rationale: Ringing in the ears. Aspirin stimulates the central nervous system which may result in ringing in the ears.
The nurse is assessing a 7 year-old after several days of treatment for a documented strep throat. Which of the following statements suggests that further teaching is needed?
- A. Sometimes I take my medicine with fruit juice.'
- B. My mother makes me take my medicine right after school.'
- C. Sometimes I take the pills in the morning and other times at night.'
- D. I am feeling much better than I did last week.'
Correct Answer: C
Rationale: Sometimes I take the pills in the morning and other times at night.' Inconsistency in taking the prescribed medication indicates more teaching is needed.
The nurse is administering the long-acting insulin glargine (Lantus) to the client at 2200. The nurse asks the charge nurse to check the dosage. Which action should the charge nurse implement?
- A. Ask the nurse why the insulin is being given late.
- B. Check the MAR versus the dosage in the syringe.
- C. Instruct the nurse to complete a medication error form.
- D. Have the nurse notify the health-care provider.
Correct Answer: B
Rationale: Verifying MAR against syringe dosage ensures accuracy, per safety protocols. Timing questions, error forms, or HCP notification are unnecessary unless errors occur.