The nurse is performing the AM assessment on a client who is ...

[student77]

The nurse is performing the AM assessment on a client who is postoperative cholecystectomy. The client states he needs his pain medication. The client has meperidine (Demerol) 50 mg IM ordered for pain.
 
  What must the nurse assess before administering a narcotic?
 
  1. The intensity of the pain only
  2. The last time the client had a bowel movement
  3. The quality, intensity, location, and duration of pain
  4. The quality of the pain only

Question 2

The nurse is caring for a client receiving morphine sulfate 24 mg IV every 4 hours as needed for pain. The client's family calls the nurses' station to request pain medication for the client.
 
  When the nurse arrives in the room, the client is lying in the bed. The nurse obtains the following vital signs: BP 120/80, P 80, and R 8. What is the nurse's first action?
 
  1. Call the physician after giving the pain medication.
  2. Call the physician.
  3. Find out when the client had the last dose of medication.
  4. Withhold the medication.

[Tonyam972]

Answer to Question 1

Correct Answer: 3

Rationale 1: The nurse needs to assess the quality, intensity, location, and duration of pain.
Rationale 2: The nurse must assess the quality, intensity, location and duration of pain. Meperidine can cause constipation, but that can be assessed at any time.
Rationale 3: The quality, intensity, location, and duration of pain need to be assessed prior to administering meperidine.
Rationale 4: The nurse needs to assess the quality, intensity, location, and duration of pain.

Global Rationale: The quality, intensity, location, and duration of pain needs to be assessed prior to administering meperidine. The last time the client had a bowel movement is not a required assessment prior to administering meperidine.

Answer to Question 2

Correct Answer: 4

Rationale 1: The medication should be withheld for respirations less than 12 breaths per minute.
Rationale 2: The first priority is to withhold the medication.
Rationale 3: The first priority is to withhold the medication.
Rationale 4: The nurse should withhold medication for any difficulty in breathing or respirations below 12 breaths per minute.

Global Rationale: The nurse should withhold medication for any difficulty in breathing or respirations below 12 breaths per minute. It is not necessary to call the physical after giving the pain medication. Although the nurse will call the physician because of the respiratory rate, this is not the priority. Although the nurse will review the time of the last dose of medication, this is not the priority.

[student77]

Excellent

[ryansturges]

TYSM