The nurse is caring for a patient who suddenly experiences chest ...

[WWatsford]

The nurse is caring for a patient who suddenly experiences chest pain. What is the nurse's first priority?
 
  a. Call the rapid response team.
  b. Ask the patient to rate and describe the pain.
  c. Raise the head of the bed.
  d. Administer pain relief medications.

Question 2

The nurse is administering pain medication for several patients. Which patient does the nurse administer medication to first?
 
  a. The patient who needs to take a scheduled dose of maintenance pain medication
  b. The patient who needs to be premedicated before walking
  c. The patient with a PCA running who needs to have the syringe replaced
  d. The patient who is experiencing 8/10 pain and has a STAT order for pain medication

[dyrone]

Answer to Question 1

ANS: B
The nurse's ability to establish a nursing diagnosis, plan and implement care, and evaluate the effectiveness of care depends on an accurate and timely assessment. The other responses are all interventions; the nurse cannot know which intervention is appropriate until the nurse completes the assessment, makes a nursing diagnosis, and plans care.

Answer to Question 2

ANS: D
STAT medications need to be given as soon as possible. In addition, this patient is the priority because of the report of severe pain. The other patients need pain medication, but their situations are not as high a priority as that of the patient with the STAT medication order.