A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first?
Determine the location of the pain.
Reposition the client.
Administer the medication.
Review the effects of the pain medication.
The Correct Answer is A
A. Determining the location of the pain is the first step, as it helps the nurse understand the nature and source of the pain, guiding appropriate intervention and medication administration.
B. Repositioning the client may provide comfort but should follow an assessment of the pain to ensure targeted interventions.
C. Administering the medication without understanding the specifics of the pain is inappropriate, as it may not adequately address the client’s needs.
D. Reviewing the effects of the pain medication is important but should occur after assessing the pain to ensure the correct medication is administered based on the client’s specific situation.
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Correct Answer is D
Explanation
A. Injecting the medication 12.7 cm (5 in) below the acromion process is incorrect; the injection site should be approximately 2.5 to 5 cm (1 to 2 inches) below the acromion process.
B. A 21-gauge needle may be appropriate for some IM injections, but a 23- to 25-gauge needle is commonly used for deltoid injections due to the smaller muscle mass.
C. While IM injections into the deltoid are typically given at a 90-degree angle, the volume of medication is the critical factor for this injection site.
D. Injecting a volume of less than 2 mL is correct, as the deltoid muscle can accommodate this amount effectively, while larger volumes should be administered in larger muscles like the vastus lateralis or gluteus medius.
Correct Answer is D
Explanation
A. Applying the pulse oximeter to a finger may not be ideal due to edema, which can affect the accuracy of the reading.
B. Using a skin fold is not a typical location for pulse oximetry and may not provide accurate readings.
C. Applying the probe to a toe may be less effective if the toenails are thickened, potentially affecting blood flow to that area and the accuracy of the reading.
D. The earlobe is a suitable alternative for measuring oxygen saturation, particularly in cases where peripheral sites (like fingers or toes) are compromised.