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.

Answer and Explanation

The Correct Answer is B

This postoperative nursing scenario requires the application of non-pharmacological pain management strategies and safety protocols. Knowledge of gate control theory and surgical contraindications is essential to address breakthrough pain effectively while awaiting provider orders without compromising the integrity of the surgical site.

Choice A rationale: While massage can be soothing, 20 minutes of back massage and effleurage is physically demanding and may not be feasible in an acute care setting. Additionally, positioning a thoracic surgery client for a back massage might cause more incisional discomfort.

Choice B rationale: Guided imagery and slow rhythmic breathing are effective non-pharmacological interventions that reduce the perception of pain by decreasing autonomic nervous system arousal. These techniques empower the client and provide immediate relief without risk of injury to the incision.

Choice C rationale: Applying heat to a fresh surgical site is contraindicated because it increases vasodilation, which can lead to increased edema, bleeding, and potential incision dehiscence. Thermal devices should never be placed directly over a fresh operative site without specific orders.

Choice D rationale: Distraction through television or music can be a helpful adjunct, but it is often less effective than active cognitive-behavioral strategies like guided imagery for a pain level of 5. It serves as a passive intervention rather than an active coping skill.

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Correct Answer is C

Explanation

Choice A reason: Offering to contact the family's spiritual counselor can provide emotional and spiritual support, but it is not the immediate priority in a situation where the client has expressed a desire to have life support withdrawn.

Choice B reason: Discussing comfort measures is important for the client and family to understand what to expect during the withdrawal process. However, this step comes after the healthcare provider has been informed and a plan of care is being developed.

Choice C reason: Informing the healthcare provider is the priority nursing intervention. The nurse acts as an advocate for the client's wishes and ensures that the appropriate steps are taken to respect the client's autonomy and decisions regarding their care.

Choice D reason: Explaining the actions that the healthcare team will follow is an essential part of the process, but it is not the first step. The healthcare provider must first be informed so that the proper orders and arrangements can be made.

A. Shufling gait. B. Urinary incontinence. C. Syncope when bending. D. Hand tremors.

Correct Answer is ["C","D"]

Explanation

Choice A rationale: A shuffling gait increases fall risk but does not directly impair ability to perform foot care or toenail trimming, so UAP assignment is not primarily indicated here.

Choice B rationale: Urinary incontinence affects bladder control, not manual dexterity or safety during foot care. It does not necessitate UAP assistance for toenail trimming or routine foot care.

Choice C rationale: Syncope when bending increases risk of fainting during foot care tasks, making independent toenail trimming unsafe. UAP support ensures safety and prevents injury during routine care.

Choice D rationale: Hand tremors impair fine motor control, making toenail trimming difficult and unsafe. UAP assistance is indicated to prevent injury and ensure proper routine foot care.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and has the client's toenails? Select all that apply.

Correct Answer is ["C","D"]

Explanation

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