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The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?

A.

Review the pain medications prescribed.

B.

Monitor the client’s nonverbal behavior.

C.

Administer PRN oral pain medication.

D.

Ask the client what is causing the grimacing.

Answer and Explanation

The Correct Answer is D

Choice A rationale

 

Administering PRN oral pain medication without further assessment may not be appropriate, as the client’s pain needs must be fully evaluated before intervening with medication. Pain medication should be administered based on an accurate assessment rather than solely on nonverbal cues.

 

Choice B rationale

 

Reviewing the pain medications prescribed is important, particularly if the client is exhibiting signs of uncontrolled pain. However, this intervention should be secondary to further assessment of the client’s current pain status.

 

Choice C rationale

 

Administering PRN oral pain medication without further assessment may not be appropriate, as the client’s pain needs must be fully evaluated before intervening with medication. Pain medication should be administered based on an accurate assessment rather than solely on nonverbal cues.

 

Choice D rationale

 

Asking the client what is causing the grimacing is the correct intervention to implement first. Nonverbal cues, such as grimacing, can indicate the presence of pain, even if the client denies it verbally. By closely monitoring the client’s nonverbal behavior, the nurse can gather additional information about the client’s pain experience and make appropriate interventions based on a comprehensive assessment.
 


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View Related questions

Correct Answer is C

Explanation

Choice A rationale

Advising the UAP to wear a standard face mask to obtain vital signs and then get fitted for a filter mask before providing personal care is not appropriate. The UAP should be properly equipped with the correct protective gear before any contact with the client.

Choice B rationale

Instructing the UAP that a standard face mask is sufficient to provide care for the assigned client is incorrect. Bacterial meningitis requires droplet precautions, and a standard face mask is sufficient for this type of precaution, not a particulate filter mask.

Choice C rationale

Sending the UAP to be fitted for a particulate filter mask immediately so the UAP can provide care to this client is unnecessary because bacterial meningitis requires droplet precautions, which only necessitate a standard surgical mask, not a particulate filter mask like an N953.

Choice D rationale

Before changing assignments, determining which staff members have fitted particulate filter masks is prudent but not necessary for caring for a client with bacterial meningitis under droplet precautions. The focus should be on ensuring the UAP understands that a standard mask is sufficient.

Correct Answer is C

Explanation

Choice A rationale

Reviewing the advanced directive document is not an immediate action to address the client’s choking and vomiting. The priority is to clear the airway and prevent aspiration.

Choice B rationale

Irrigating the nasogastric tube with water is not appropriate in this situation as it may worsen the choking and does not address the immediate need to clear the airway.

Choice C rationale

Elevating the head of the bed 45 degrees helps to clear the airway and reduce the risk of aspiration by using gravity to keep the stomach contents down.

Choice D rationale

Performing oropharyngeal suctioning may stimulate gagging and vomiting, which can exacerbate the choking.

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