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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Coagulation studies: Hydrochlorothiazide does not typically affect coagulation parameters, making this unnecessary for routine monitoring.
B. Thyroid levels: Hydrochlorothiazide does not interfere with thyroid function.
C. Complete blood count: Although monitoring general blood health is important, hydrochlorothiazide primarily affects electrolytes.
D. Serum electrolyte levels: Hydrochlorothiazide is a diuretic that can cause electrolyte imbalances, including hypokalemia, hyponatremia, and hypercalcemia. Regular monitoring is essential.
Correct Answer is A
Explanation
A. Sore throat: Sore throat is a potential sign of agranulocytosis, a serious adverse effect of carbamazepine, and should be reported to the provider immediately.
B. Increased salivation: Increased salivation is not typically associated with carbamazepine and is not considered a common adverse effect.
C. Urge incontinence: Urge incontinence is not a known adverse effect of carbamazepine.
D. Gingivitis: Gingivitis is not a typical adverse effect of carbamazepine and is not generally a concern for this medication.
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