In my blog post from last week, we talked about how to identify assessment versus analysis type NCLEX questions, and how that can help you decide what type of answer choice you should be looking for. Last week, we decided that our example question required an assessment, so let’s review the question and look at the answer choices.
Question: The client has asked for their next dose of morphine. The medication order is for 2mg q4h prn for pain, and it has been four hours since the client’s last dose. Which of the following would be the best nursing action to take?
A) Notify the doctor that the client is still having pain.
B) Assess the client’s respiratory rate and heart rate.
C) Ask the client to rate their pain on a scale of 1-10.
D) Teach the client a deep breathing exercise.
Now that you’ve looked at the answers, put yourself into the situation and ask yourself even more questions. What kinds of things should you be thinking about? What do you know about morphine? What do you know about pain management? Should you go ahead and give him the morphine, or should you do something else first? What do you think this question is trying to test you on? Here’s a hint: test writers want to know if you can be a safe and effective BEGINNING nurse, they’re really not trying to trick you.
Since we decided last week that this seems like an assessment question, we already know that we need to gather more information before we can safely administer the morphine. That means you can eliminate “A” and “D” right away, because both of them are interventions, not assessments to gather information.
That leaves “B” and “C.” Which to do? Keep asking yourself some questions, and imagine yourself in that situation. Both are things that you would do eventually, but when they ask for the “best” nursing action to take, then you can only pick one! This is what makes NCLEX-type questions so difficult…there are usually more than one correct answers available, but you need to pick the BEST correct answer.
Ok, so I narrowed it down to 2 options for you…which do you think? Leave a comment below with your educated guess and rationale…then maybe I’ll tell you the answer 🙂
Nicole is a Professional Nursing Tutor with over 15 years experience, and the founder of Your Nursing Tutor. She has a BSN, and an MA in Clinical Psychology. Nicole specializes in providing easy-to-follow, proven study methods (like the Silver Bullet Study System) that transform frustrated nursing students into calm, confident nurses! When she’s not helping students through her Live Tutoring Membership, Nicole loves spending time with her husband, homeschooling their 6 kids, and staring at sunflowers.
lol…ok I’ll bite. I’m honestly not sure and always after I answer these kind of questions the “rationale” always makes perfect sense but before hand…yikes! (C) The order does indeed specify the morphine can be given every 4 hours for pain but the nurse doesn’t know what the patients current pain level is he may just be asking because he knows its been 4 hours and at first guess it may seem like it would be ok to give. However, (B) morphine can cause bradycardia and respiratory depression (to name a few) so I would want to FIRST make sure this patient was not having any issues with this drug that could affect his ability to breathe (rather important) and assess if it was safe to administer abother dose of morphine at this time.
Well?? Please? 🙂
Thanks for making an educated guess, Lisa! And good thought processes for both answer choices.
What can help you narrow it down is to put yourself in the situation and think about what you would do FIRST, and which action would be MOST related to the question. Although the patient is asking for his prescribed morphine, we have no other indication in the question that he is even having any pain! So the first thing we need to assess is their pain level, making the answer “C.” If their pain level is very low, then we might need to educate the patient a little on the use of morphine.
If their pain level is high enough to warrant another dose of morphine, THEN we would want to make sure to assess HR and respiratory rate before we give the medication. But first, let’s check their pain level to make sure it’s even needed.