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.

Answer and Explanation

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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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Inject 0.3 to 0.5 mL of the solution: The typical volume for a tuberculin skin test is 0.1 mL.
B. Select an injection site that is free of scar tissue: Scar tissue can interfere with the reading of the tuberculin skin test, so a site free of scars should be selected.
C. Hold the needle at a 30° angle during injection: The needle should be held at a 5–15° angle for intradermal injections.
D. Massage the site following the injection: Massaging the site is not recommended as it could affect the accuracy of the test.

A. Hydrochlorothiazide B. Lisinopril C. Atenolol D. Aspirin

Correct Answer is C

Explanation

A. Hydrochlorothiazide does not affect heart rate and can be safely given.
B. Lisinopril does not cause bradycardia.
C. Atenolol is a beta-blocker that slows heart rate; withholding is necessary for bradycardia.
D. Aspirin does not influence heart rate and is not contraindicated.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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