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 B
Explanation
A. An adolescent who received a new tattoo last week: A tattoo does not contraindicate live vaccines.
B. A client is at 27 weeks of gestation: Live attenuated vaccines are contraindicated in pregnancy due to potential risk to the fetus.
C. A client who is about to travel to a different country: Travel does not contraindicate the vaccine unless the client has other risk factors.
D. A school-age child who has rhinitis: Mild illness such as rhinitis does not contraindicate live vaccines.
Correct Answer is ["0.85"]
Explanation
Volume to administer = Prescribed dose/ available concentration
= 17, 000 units/20, 000 units/mL
= 0.85 mL
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