A nurse is caring for a client who had abdominal surgery. The client is grimacing and has a respiratory rate of 24/min. Which of the following actions should the nurse take first?
Offer the client a cold compress.
Play music in the client's room as a distraction.
Check the client's current level of pain.
Assist the client to reposition in bed.
The Correct Answer is C
A. Offer the client a cold compress: While a cold compress might help with swelling or discomfort, it is more important to assess the client's pain level first to understand the cause of the grimacing.
B. Play music in the client's room as a distraction: This could help later, but pain needs to be addressed first.
C. Check the client's current level of pain: Grimacing could indicate pain, which should be evaluated and addressed first to provide comfort and prevent complications like increased stress or decreased respiratory effort.
D. Assist the client to reposition in bed: Repositioning could help alleviate discomfort, but pain should be assessed first to ensure the client is not in severe pain.
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Related Questions
Correct Answer is D
Explanation
A. Troponin: Troponin is used to evaluate cardiac injury, not the effectiveness of epoetin alfa.
B. Thyroxine (T4): T4 measures thyroid function, unrelated to epoetin alfa.
C. Aspartate aminotransferase (AST): AST is a liver enzyme, not used to monitor epoetin alfa therapy.
D. Hgb: Epoetin alfa stimulates erythropoiesis to increase hemoglobin levels in clients with anemia, particularly in chronic kidney disease or chemotherapy.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
Rationale:
The client’s blood pressure of 80/46 mm Hg indicates hypotension, likely due to dehydration from persistent diarrhea. This is the most critical finding, as it can lead to organ hypoperfusion and shock if not addressed immediately. After stabilizing the client’s blood pressure, the nurse should address the client’s low potassium level (3.1 mEq/L), as hypokalemia can cause serious complications, including cardiac arrhythmias.
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