A nurse is caring for a client who had surgery 2 days ago and reports incisional pain. Which of the following actions should the nurse take first?
Determine the time the last dose of pain medication was administered.
Reposition the client to assist with reduction of pain.
Ask the client to describe the pain and rate it on a scale of 0 to 10.
Check the client’s medical record for type of PRN pain medication.
The Correct Answer is C
Choice A Reason
Determine the time the last dose of pain medication was administered. While it is important to know when the last dose of pain medication was given, assessing the client’s current pain level is a priority. This helps in understanding the severity and nature of the pain, which guides further interventions.
Choice B Reason
Reposition the client to assist with reduction of pain. Repositioning can help alleviate pain, but it should be done after assessing the pain. Without understanding the pain’s characteristics, repositioning might not address the underlying issue effectively.
Choice C Reason
Ask the client to describe the pain and rate it on a scale of 0 to 10. This is the correct first action. Pain assessment is crucial in determining the appropriate intervention. By asking the client to describe and rate their pain, the nurse can tailor the pain management plan to the client’s specific needs.
Choice D Reason
Check the client’s medical record for type of PRN pain medication. Reviewing the medical record for PRN pain medication is important, but it should follow the initial pain assessment. Knowing the pain’s intensity and characteristics will help in deciding whether PRN medication is needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason
Maintain strict bed rest. This intervention is not typically recommended for managing Ménière’s disease. While rest during acute vertigo episodes is important, strict bed rest is not necessary and can lead to other complications such as muscle atrophy and decreased mobility.
Choice B Reason
Restrict fluid intake to the morning hours. This statement is incorrect. Fluid intake should be evenly distributed throughout the day to help manage the symptoms of Ménière’s disease. Restricting fluids to the morning hours can lead to dehydration and does not effectively manage the condition.
Choice C Reason
Administer aspirin. This intervention is not recommended for Ménière’s disease. Aspirin can worsen tinnitus, a common symptom of Ménière’s disease, and is generally avoided in these patients.
Choice D Reason
Provide a low-sodium diet. This is the correct intervention. A low-sodium diet helps reduce fluid retention in the body, which can decrease the pressure in the inner ear and help manage the symptoms of Ménière’s disease. Reducing sodium intake to 1,500-2,000 milligrams per day is often recommended.
Correct Answer is B
Explanation
Choice A Reason:
Notifying the provider if you experience a stinging sensation following administration is not necessary. A mild stinging sensation is a common side effect of timolol eye drops and usually subsides quickly. However, if the stinging persists or is severe, it should be reported.
Choice B Reason:
Watching for a decreased heart rate while using this medication is important. Timolol is a beta-blocker, and one of its systemic side effects can be bradycardia (a slower than normal heart rate). Patients should be aware of this potential side effect and monitor their heart rate regularly.
Choice C Reason:
Developing a harmless darkening of the iris is not associated with timolol. This side effect is more commonly linked to prostaglandin analogs, another class of medications used to treat glaucoma.
Choice D Reason:
Timolol does not cause the lashes of the affected eye to lengthen. This side effect is also associated with prostaglandin analogs, not beta-blockers like timolol.
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