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 A
Explanation
A. Checking the client for allergies is the first step in ensuring the safety of medication administration; it is crucial to verify that the client does not have any known allergies to the medication before proceeding.
B. Documenting that the medication was administered should occur after the medication has been given, not before.
C. Mixing the medication at the client’s bedside is an important step, but it should be done only after confirming that the medication is appropriate for the client.
D. Determining the client's response to the medication occurs after administration, making it a follow-up action rather than a first step.
Correct Answer is ["B","E"]
Explanation
A. The provider's name is not an acceptable identifier for verifying the client; it does not confirm the identity of the patient receiving the medication.
B. A facility-assigned identification number is an acceptable identifier as it uniquely identifies the client within the healthcare system.
C. The facility room number is not reliable for identifying clients, as multiple clients can be in the same room or there could be room changes.
D. The partner's full name is not an appropriate identifier for the client; it does not confirm the identity of the patient.
E. The client's full name is an acceptable identifier as it is a primary method to verify the identity of the client before medication administration.