A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions.

Which of the following responses should the nurse make?

"You can apply counterpressure to your back with each position change."

"You can splint the incision with a pillow when changing positions."

"You should change positions as little as possible."

"You should use patterned-paced breathing when changing positions."

Answer and Explanation

The Correct Answer is B

Splinting the incision with a pillow when changing positions can provide support and help minimize discomfort and pain in clients who have undergone a cesarean birth. It can help reduce strain on the incision site and provide a sense of stability and comfort.

"You can apply counterpressure to your back with each position change" may be helpful for managing back pain, but it does not specifically address the client's request for nonpharmacological interventions to manage pain when changing positions after a cesarean birth.

"You should change positions as little as possible" is not an appropriate response as it does not address the client's need to manage pain when changing positions. Encouraging movement and position changes, along with appropriate support, can aid in recovery and prevent complications such as blood clots and respiratory issues.

"You should use patterned-paced breathing when changing positions" is not specifically related to managing pain when changing positions after a cesarean birth. While breathing techniques can be useful for pain management during labor and certain procedures, it may not be the most effective strategy for managing pain when changing positions post-cesarean.

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Correct Answer is A

Explanation

Insulin lispro is a rapid-acting insulin, while insulin glargine is a long-acting insulin. It is important to keep them separate to maintain their individual properties and avoid any potential interactions or changes in their effectiveness.

Insulin glargine is a clear solution and should not appear cloudy. Cloudiness in insulin can indicate contamination or improper storage.

The instruction to "take an extra dose of insulin lispro prior to aerobic exercise" is not recommended. The client should consult with their healthcare provider to determine if any adjustments to their insulin regimen are necessary for exercise. Typically, adjustments are made based on the individual's blood glucose levels and anticipated intensity and duration of exercise. Insulin glargine is a long-acting insulin that provides a steady release of insulin over a prolonged period, without distinct peaks or valleys in its action. Its onset of action is gradual and its effect lasts for approximately 24 hours.

It is important for the client to receive accurate and appropriate instructions regarding their insulin regimen. The nurse should clarify any misunderstandings and provide accurate information to promote safe and effective diabetes management.

A. Assign clients to the remaining staff. B. Document objective findings about the situation. C. Remove the nurse from the client care area. D. Call the supervisor to ask for another nurse.

Correct Answer is C

Explanation

When a charge nurse observes the smell of alcohol on a nurse's breath, it raises concerns about their ability to provide safe and competent care to clients. Patient safety is of utmost importance, and the charge nurse must take immediate action to address the situation.

Removing the nurse from the client care area ensures that the nurse is not involved in direct patient care while their ability to provide safe care is in question. This step helps mitigate potential risks to patient safety.

B and D- After removing the nurse from the client care area, further actions can be taken, such as documenting the objective findings about the situation and informing the supervisor. However, the immediate priority is to ensure patient safety by removing the nurse from the care area.

A- Assigning clients to the remaining staff can be done once the situation has been addressed and a suitable replacement for the nurse has been arranged.

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A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is C

Explanation

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A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions.

Which of the following responses should the nurse make?