a nurse is caring for a client who reports pain after medication the client continues to express discomfort what is the next best step
Logo

Nursing Elites

HESI LPN

Adult Health Exam 1

1. A client reports pain after medication administration. What is the next best step for the nurse?

Correct answer: A

Rationale: The correct answer is to reassess the client’s pain. Reassessment is essential to evaluate the effectiveness of the initial intervention. By reassessing, the nurse can determine if the current pain management plan is adequate or if further interventions are required. Increasing the pain medication dose without reassessment can lead to overmedication and potential adverse effects. Applying a cold compress may not address the underlying cause of the pain and should be based on a proper assessment. Contacting the healthcare provider should be considered if the reassessment indicates a need for further evaluation or intervention beyond the nurse's scope of practice.

2. After placement of a left subclavian central venous catheter (CVC), the nurse receives a report of the X-ray findings indicating that the CVC tip is in the client's superior vena cava. Which action should the nurse implement?

Correct answer: B

Rationale: Initiating intravenous fluids as prescribed is the appropriate action when the CVC tip is correctly placed in the superior vena cava. Intravenous fluids can now be administered effectively through the central line. Removing the catheter and applying direct pressure is unnecessary and not indicated as the tip is in the correct position. Securing the catheter using aseptic technique is important for preventing infections but is not the immediate action needed in this situation. Notifying the healthcare provider of the need to reposition the catheter may delay necessary fluid administration, which is the priority at this time.

3. A client with a diagnosis of anemia is being discharged with a prescription for ferrous sulfate. What should the nurse include in the teaching plan?

Correct answer: B

Rationale: The correct answer is B: 'Expect stools to be dark in color.' Dark stools are a common side effect of iron supplementation due to the unabsorbed iron, and this is not a cause for concern. Choice A is incorrect because taking iron with milk can decrease its absorption due to calcium binding. Choice C is incorrect as there are no specific recommendations to take ferrous sulfate before bedtime. Choice D is also incorrect as vitamin C actually enhances iron absorption and should not be avoided.

4. A client has a prescription for enteric-coated (EC) aspirin 325mg PO daily. The medication drawer contains one 325mg aspirin. What action should the nurse take?

Correct answer: A

Rationale: The correct action for the nurse to take is to contact the pharmacy and request the prescribed form of aspirin. Enteric-coated medications are designed to dissolve in the intestine, not the stomach, to avoid irritation. Therefore, it is essential to ensure the client receives the correct form of aspirin as prescribed. Instructing the client about the effects of the medication (choice B) is not necessary at this point as the issue is related to the form of the aspirin. Administering the aspirin with a full glass of water or a small snack (choice C) is not appropriate as it does not address the need for the correct form of the medication. Withholding the aspirin (choice D) without consulting the healthcare provider is not advisable as it may lead to a delay in the client receiving the necessary medication.

5. A client is scheduled for an abdominal ultrasound in the morning and has been instructed to fast overnight. The client asks the nurse why fasting is necessary. What is the best response?

Correct answer: B

Rationale: The correct answer is B: 'It ensures clearer imaging by emptying the stomach.' Fasting before an abdominal ultrasound is essential to empty the stomach, allowing for better visualization of the abdominal organs. This improves the quality of the imaging and enhances diagnostic accuracy. Choices A, C, and D are incorrect because reducing intestinal gases, preventing aspiration, and being a standard procedure for surgical interventions are not the primary reasons for fasting before an abdominal ultrasound.

Similar Questions

A client with a history of hypertension is prescribed hydrochlorothiazide (HCTZ). Which adverse effect should the nurse monitor for?
4 hours after administration of 20U of regular insulin, the client becomes shaky and diaphoretic. What action should the nurse take?
After placing a client at 26-weeks gestation in the lithotomy position, the client complains of dizziness and becomes pale and diaphoretic. What action should the nurse implement?
The nurse is assessing a client with left-sided heart failure. Which symptom should the nurse expect to find?
A new father asks the nurse the reason for placing an ophthalmic ointment in his newborn's eyes. What information should the nurse provide?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses