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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A Reason:

Carbidopa/levodopa can cause the urine to turn a dark color, such as red, brown, or black. This is a harmless side effect but can be alarming to patients if they are not forewarned. Informing patients about this potential change helps to prevent unnecessary concern.

Choice B Reason:

Expecting immediate relief after taking carbidopa/levodopa is not accurate. While some patients may experience symptom relief relatively quickly, it often takes several weeks for the full therapeutic effects to be realized. Patients should be advised to continue taking the medication as prescribed and to communicate with their healthcare provider about their progress.

Choice C Reason:

Taking carbidopa/levodopa with high-protein food is not recommended. High-protein foods can interfere with the absorption of the medication, reducing its effectiveness. It is generally advised to take the medication on an empty stomach or with a low-protein snack.

Choice D Reason:

Skipping a dose of the medication if experiencing dizziness is not advisable. Dizziness can be a side effect of carbidopa/levodopa, but it should be managed by adjusting the dose or timing of the medication rather than skipping doses. Patients should discuss any side effects with their healthcare provider to find the best management strategy.

A. Use an electric shaver. B. Avoid crowds. C. Take temperature weekly. D. Consume a low-residue diet. E. Monitor for bruising.

Correct Answer is ["A","B","E"]

Explanation

Choice A Reason:

Using an electric shaver is recommended for clients who have received chemotherapy because it reduces the risk of cuts and bleeding. Chemotherapy can lower platelet counts, leading to an increased risk of bleeding. Traditional razors can cause nicks and cuts, which can be problematic for clients with low platelet counts.

Choice B Reason:

Avoiding crowds is crucial for clients who have received chemotherapy because their immune systems are often weakened, making them more susceptible to infections. Crowded places increase the risk of exposure to pathogens, which can lead to serious infections in immunocompromised individuals.

Choice C Reason:

Taking temperature weekly is not sufficient for clients who have received chemotherapy. These clients are at a higher risk of infections, and any sign of fever should be monitored closely. It is generally recommended to take the temperature daily or more frequently if the client feels unwell.

Choice D Reason:

Consuming a low-residue diet is not typically necessary for clients who have received chemotherapy unless they are experiencing specific gastrointestinal issues. A balanced diet with adequate nutrients is usually recommended to support overall health and recovery.

Choice E Reason:

Monitoring for bruising is important for clients who have received chemotherapy because it can indicate low platelet counts or other bleeding disorders. Early detection of bruising can help in managing and preventing more serious bleeding complications.

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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?

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