A client who is 2 days postoperative for thoracic surgery is reporting incisional pain 2 hours after receiving pain medication. The client rates the pain as 5 on a pain scale of 0 to 10. After placing a call to the healthcare provider, which action should the nurse implement?
Provide at least 20 minutes of back massage and gentle efleurage.
Instruct the client to use guided imagery and slow rhythmic breathing.
Place a hot water circulation device, such as an aquathermia pad, on the operative site.
Tune to a television show or easy listening music to provide distraction.
The Correct Answer is A
Choice A reason: Providing a back massage and gentle efleurage can help alleviate pain through relaxation
techniques and is a non-pharmacological method to manage pain.
Choice B reason: Guided imagery and slow rhythmic breathing are helpful relaxation techniques, but they may not be as immediately effective for incisional pain as direct physical interventions.
Choice C reason: The use of a hot water circulation device should be done with caution postoperatively, as it may not be appropriate depending on the surgical site and the client's condition.
Choice D reason: Distraction techniques like watching television or listening to music can be helpful, but they may not address the physical component of the client's incisional pain.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Recording the client's pulse rate and rhythm is part of the assessment, but it is not the first action to take when assessing for orthostatic hypotension.
Choice B reason: Assisting the client to stand is part of the assessment process, but it should be done after the initial blood pressure and pulse have been measured while the client is supine.
Choice C reason: Applying the blood pressure cuff securely is necessary for an accurate reading, but it is not the first step in the process of assessing for orthostatic hypotension.
Choice D reason: The first action is to position the client supine for a few minutes before taking the initial blood pressure and pulse measurements, as this provides a baseline for comparison when the client stands.
Correct Answer is B
Explanation
Choice A reason: The Trendelenburg position is not indicated for increasing oxygen saturation and could be harmful, especially for clients with respiratory distress.
Choice B reason: Ensuring that the prongs of the nasal cannula are securely placed in the nostrils is important for effective oxygen delivery, especially if the oxygen saturation remains below the prescribed range.
Choice C reason: Placing the pulse oximeter on the client's earlobe is an alternative site for obtaining a saturation reading, but it does not address the issue of potentially inadequate oxygen delivery.
Choice D reason: While documentation is important, the nurse must first address the low oxygen saturation levels before documenting the readings.
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