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 B
Explanation
Choice A reason: Utilize supine positioning to maximize chest expansion is not an important intervention for clients with a BMI greater than or equal to 30. Supine positioning is when the client lies flat on their back. This position can actually impair chest expansion and breathing for clients with a high BMI, as the weight of the abdomen and chest can compress the lungs and diaphragm. A semi-Fowler's position, where the head of the bed is elevated at 30 to 45 degrees, is preferred for these clients, as it reduces the pressure on the chest and improves ventilation.
Choice B reason: Use an appropriately sized blood pressure cuff is an important intervention for clients with a BMI greater than or equal to 30. A blood pressure cuff that is too small or too tight can cause inaccurate readings and increase the risk of injury to the client. A blood pressure cuff that is too large or too loose can also cause inaccurate readings and compromise the quality of care. A blood pressure cuff that fits the client's arm circumference and width is essential for obtaining accurate and reliable measurements and preventing complications.
Choice C reason: Consult a nutritionist because the client is malnourished/underweight is not an important intervention for clients with a BMI greater than or equal to 30. A BMI greater than or equal to 30 indicates that the client is obese, not malnourished or underweight. Obesity is a condition where the client has excess body fat that can affect their health and well-being. Malnutrition is a condition where the client has inadequate or imbalanced intake of nutrients that can affect their growth and development. Underweight is a condition where the client has a low body weight that can affect their immunity and energy. A nutritionist can help clients with any of these conditions, but the statement is incorrect for clients with a high BMI.
Choice D reason: Place the client on fall precautions because of increased risk for falls due to frail bones is not an important intervention for clients with a BMI greater than or equal to 30. Frail bones are not a common consequence of obesity, but rather of osteoporosis, a condition where the bones become weak and brittle. Obesity can actually increase the bone density and strength, as the bones have to support more weight. However, obesity can increase the risk for falls due to other factors, such as impaired mobility, balance, or coordination. Fall precautions are important for any client who is at risk for falls, but the statement is inaccurate for clients with a high BMI.
Correct Answer is D
Explanation
Choice A reason: Nurses can accomplish more if they perform the easiest or fastest interventions is not a primary reason for prioritizing care. This statement implies that nurses should focus on the quantity rather than the quality of care. However, nurses should prioritize care based on the urgency and complexity of the patient's needs, not on the ease or speed of the interventions. Performing the easiest or fastest interventions may not address the most important or critical issues that the patient faces.
Choice B reason: Nurses should always perform interventions related to client preference early in the shift is not a primary reason for prioritizing care. This statement implies that nurses should base their care on the patient's wishes rather than the patient's condition. However, nurses should prioritize care based on the severity and acuity of the patient's problems, not on the patient's preference. Performing interventions related to client preference early in the shift may not be feasible or appropriate if the patient has more urgent or emergent needs that require immediate attention.
Choice C reason: Nurses need to plan how to accomplish all activities within one shift is not a primary reason for prioritizing care. This statement implies that nurses should focus on the completion rather than the quality of care. However, nurses should prioritize care based on the significance and impact of the patient's outcomes, not on the completion of the activities. Accomplishing all activities within one shift may not be possible or necessary if the patient's situation changes or if some activities can be delegated or postponed.
Choice D reason: Nurses have a limited amount of time to perform nursing interventions during a shift is a primary reason for prioritizing care. This statement acknowledges that nurses face time constraints and competing demands in their work environment. Therefore, nurses should prioritize care based on the best use of their time and resources to meet the patient's needs. Having a limited amount of time to perform nursing interventions during a shift requires nurses to make clinical judgments and decisions that optimize the patient's health and safety.
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