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

Explanation

The correct answer isChoice A, Choice C, and Choice D.

Choice A rationale:A shuffling gait can indicate mobility issues, making it difficult for the client to safely perform foot care and toenail clipping. This increases the risk of falls and injuries.

Choice B rationale:Urinary incontinence does not directly affect the ability to perform foot care or toenail clipping. It is more related to bladder control issues.

Choice C rationale:Syncope when bending suggests that the client may experience dizziness or fainting when bending over, making it unsafe for them to perform foot care and toenail clipping.

Choice D rationale:Hand tremors can make it challenging for the client to handle nail clippers or other tools needed for foot care, increasing the risk of injury.

A. Praise the UAP for using standard precautions. B. Instruct the UAP to change gloves immediately. C. Request that an in-service program be scheduled on asepsis. D. Submit an adverse occurrence report to the unit manager.

Correct Answer is B

Explanation

Choice A reason: Praising the UAP for using standard precautions is not appropriate in this situation as using the same gloves for multiple clients breaches infection control protocols.

Choice B reason: The nurse should instruct the UAP to change gloves immediately to prevent cross-contamination between clients.

Choice C reason: While scheduling an in-service program on asepsis is beneficial for long-term education, it does not address the immediate risk of infection.

Choice D reason: Submitting an adverse occurrence report may be necessary if there is a pattern of non-compliance, but the first action should be to correct the behavior and ensure client safety.

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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

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 ["A","C","D"]

Explanation

The nurse observes an unlicensed assistive personnel (UAP) providing care for two clients using the same gloves. Which action should the nurse take first?

Correct Answer is B

Explanation

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