A client continues to report post-surgical incision pain at a level of 9 out of 10 after pain medication is given. The next dose of pain medicine is not due for another hour. What should the critically thinking nurse do first?
Offer to notify the health care provider after morning rounds are completed
Explore other options for pain relief
Discuss the surgical procedure and reason for the pain
Explain to the patient that nothing else has been ordered
The Correct Answer is B
Choice A reason: This is not the correct answer because offering to notify the health care provider after morning rounds are completed is not the first action that the critically thinking nurse should take. The nurse should act promptly and advocate for the patient's pain management needs, rather than delaying the communication with the health care provider.
Choice B reason: This is the correct answer because exploring other options for pain relief is the first action that the critically thinking nurse should take. The nurse should assess the patient's pain level, location, quality, and contributing factors, and use a multimodal approach to pain management that includes pharmacological and non-pharmacological interventions, such as ice, heat, distraction, relaxation, or massage.
Choice C reason: This is not the correct answer because discussing the surgical procedure and reason for the pain is not the first action that the critically thinking nurse should take. The nurse should focus on alleviating the patient's pain, rather than educating the patient about the surgery. The nurse can provide information and reassurance to the patient after the pain is controlled.
Choice D reason: This is not the correct answer because explaining to the patient that nothing else has been ordered is not the first action that the critically thinking nurse should take. The nurse should not dismiss the patient's pain or imply that the patient has no other options for pain relief. The nurse should collaborate with the patient and the health care provider to find the best pain management plan for the patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Vitamin D is a fat-soluble vitamin that helps the body absorb calcium and phosphorus, which are essential for bone health. The main source of vitamin D is exposure to sunlight, which triggers the skin to produce it. The nurse should advise the client to spend at least 15 minutes outdoors every day, preferably in the morning or evening, when the sun is not too strong. The client should also wear sunscreen and protective clothing to prevent sunburn and skin damage.
Choice B reason: Reducing the amount of cereal in the diet is not a good recommendation for increasing vitamin D intake. Cereal is often fortified with vitamin D and other nutrients, such as iron and folic acid. The nurse should encourage the client to choose cereals that are high in vitamin D and low in sugar and fat. The client should also consume other foods that are rich in vitamin D, such as fatty fish, egg yolks, cheese, and mushrooms.
Choice C reason: Increasing intake of dietary calcium is important for preventing and treating osteoporosis, but it does not directly affect vitamin D intake. Calcium is a mineral that helps build and maintain strong bones and teeth. The nurse should recommend the client to consume foods that are high in calcium, such as dairy products, leafy greens, nuts, and tofu. The client should also take a calcium supplement if needed, as prescribed by the provider.
Choice D reason: Adding a regular exercise routine is beneficial for improving overall health and well-being, but it does not directly influence vitamin D intake. Exercise helps strengthen the muscles and bones, prevent falls and fractures, and reduce the risk of chronic diseases. The nurse should suggest the client to engage in moderate physical activity for at least 30 minutes a day, three times a week. The client should choose exercises that are appropriate for their age and fitness level, such as walking, swimming, or yoga.
Correct Answer is C
Explanation
Choice A reason: Cataracts are a condition that causes the lens of the eye to become cloudy and opaque. They can cause symptoms such as blurred vision, glare, halos, and reduced color perception. They do not affect the shape of the lines on the Amsler grid or the center of vision.
Choice B reason: Glaucoma is a condition that causes increased pressure in the eye and damage to the optic nerve. It can cause symptoms such as gradual loss of peripheral vision, tunnel vision, and eye pain. It does not affect the shape of the lines on the Amsler grid or the center of vision.
Choice C reason: Macular degeneration is a condition that affects the macula, the central part of the retina. It can cause symptoms such as distorted vision, dark spots, and loss of central vision. It can affect the shape of the lines on the Amsler grid and the center of vision.
Choice D reason: Retinal detachment is a condition that occurs when the retina separates from the back of the eye. It can cause symptoms such as flashes, floaters, and a curtain-like vision loss. It does not affect the shape of the lines on the Amsler grid or the center of vision.
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