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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Weight gain: Methimazole is used to treat hyperthyroidism, and effective treatment often leads to weight gain, as metabolism normalizes.
B. Decreased menstrual flow: Methimazole can affect menstrual cycles, but decreased flow is not an indicator of effectiveness.
C. Clear breath sounds: This is not related to the effectiveness of methimazole.
D. Increased libido: Changes in libido are not a direct indicator of methimazole’s effectiveness.
Correct Answer is A
Explanation
A. Withdraw the NPH insulin last: When mixing insulin, the regular (clear) insulin should be drawn into the syringe first, followed by the NPH (cloudy) insulin to avoid contaminating the regular insulin.
B. Mix the medications in a 3-mL syringe: While mixing is correct, the syringe size is not specifically relevant unless the total dose exceeds the syringe capacity. A standard insulin syringe should be used.
C. Administer the medications in two separate syringes: This is unnecessary when mixing regular and NPH insulin is appropriate.
D. Inject air into the regular vial first: Air should be injected into the NPH vial first, then the regular vial.
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