The nurse is caring for an adolescent who complains of a headache. The nurse dims the light in the room, administers the ordered pain medication, and provides the adolescent with a caffeinated soda
Which of the following is the correct method of evaluating the effectiveness of this intervention? 1. Take the client's vital signs.
2. Ask the parents if the client is feeling better.
3. Observe the adolescent for signs of pain.
4. Ask the adolescent to rate the pain in one hour.
4
Rationale 1: Pain is a subjective symptom that only the client can describe. Asking the parents to report the client's status and observing for signs of pain would yield secondary data, while asking the client directly provides more valuable information to evaluate outcome.
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A client has a pyloric obstruction and reports sudden muscle weakness. What action by the nurse takes priority?
a. Document the findings in the chart. b. Request an electrocardiogram (ECG). c. Facilitate a serum potassium test. d. Place the client on bedrest.
When using an otoscope to assess the client's ear, the nurse notes that the tympanic membrane moves in response to air injected into the external canal. Which of the following should the nurse do?
A. Immediately remove the otoscope to prevent infection. B. Document the finding. C. Prepare to wash the external ear canal. D. Notify the physician.
The nurse is performing a health history on a patient who has arthritis. The patient reports tinnitus. Suspecting a drug adverse effect, the nurse will ask the patient about which medication?
a. Aspirin (Bayer) b. Acetaminophen (Tylenol) c. Anakinra (Kineret) d. Prednisone (Deltasone)
To reduce a nurse's exposure to chemotherapy drugs during IV administration, what is the nurse's highest priority nursing intervention?
a. Wear a mask during administration of the medication. b. Clean up a spill with paper towels as quickly as possible. c. Wear a face shield if there is any danger of splashing. d. Wear triple-layered gloves during administration.