A nurse is assessing a client for acute postoperative pain. Which of the following actions should the nurse take first?

Provide an analgesic for pain.

Obtain a self-report from the client.

Observe the client's behaviors.

Develop a behavioral pain score.

Answer and Explanation

The Correct Answer is B

A. Provide an analgesic for pain. Administering medication is important but should be done after assessing the pain.
B. Obtain a self-report from the client. The client's self-report is the most reliable indicator of pain and should be obtained first.
C. Observe the client's behaviors. Observing behaviors is helpful but should follow the self-report to validate the client's experience.
D. Develop a behavioral pain score. This can be useful for non-verbal clients, but the self-report is the primary method of assessment for verbal clients.

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Correct Answer is D

Explanation

A. Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) used for short-term pain management but is not typically used for fibromyalgia-related pain.
B. Oxycodone is an opioid pain medication, but it is generally not recommended for fibromyalgia due to potential side effects and the risk of dependence.
C. Ibuprofen, another NSAID, can help with pain and inflammation but is not typically the first choice for fibromyalgia, which often requires medications targeting nerve pain.
D. Gabapentin is commonly used to manage nerve pain associated with fibromyalgia. It is effective for the burning pain often experienced by fibromyalgia patients.

A. "Report a firm ridge below the breasts to the provider." B. "Keep your arm relaxed at your side on the side you are examining." C. "Use your thumb and forefinger to palpate each breast for lumps." D. "Use firm pressure to palpate near the area of the ribs and chest wall."

Correct Answer is D

Explanation

A. "Report a firm ridge below the breasts to the provider." A firm ridge along the bottom curve of the breast can be normal. It’s important to distinguish between normal breast tissue and abnormal lumps. Encouraging clients to report any changes or new lumps to the provider is more appropriate.
B. "Keep your arm relaxed at your side on the side you are examining." The correct technique involves raising the arm on the side being examined to help spread out the breast tissue, making it easier to palpate for lumps and abnormalities.
C. "Use your thumb and forefinger to palpate each breast for lumps." The correct technique involves using the pads of the fingers (not the thumb and forefinger) to palpate the breast in a systematic pattern, such as circular motions or vertical strips, to thoroughly check all areas of the breast.
D. "Use firm pressure to palpate near the area of the ribs and chest wall." Using firm pressure is appropriate for palpating deeper tissues closer to the ribs and chest wall, as this helps detect lumps that may not be superficial.

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A nurse is assessing a client for acute postoperative pain. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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