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 B
Explanation
Choice A Reason
Request a prescription for an antibiotic. This intervention is not typically included in the standard care plan for all COPD patients. Antibiotics are generally reserved for cases of acute exacerbations of COPD (AECOPD) with signs of bacterial infection, such as increased dyspnea, increased sputum purulence, and increased sputum volume. Routine use of antibiotics without these signs is not recommended.
Choice B Reason
Educate the client on pursed-lip breathing. This is the correct intervention. Pursed-lip breathing is a technique that helps improve ventilation, release trapped air in the lungs, and reduce the work of breathing. It is particularly beneficial for patients with COPD as it helps them manage shortness of breath and improve their breathing efficiency.
Choice C Reason
Place the client on airborne precautions. This intervention is incorrect. COPD is not an infectious disease that requires airborne precautions. Airborne precautions are used for diseases that are transmitted through the air, such as tuberculosis. COPD management focuses on improving lung function and preventing exacerbations.
Choice D Reason
Initiate oxygen therapy for SpO₂ of 92%. This intervention is partially correct but needs clarification. Oxygen therapy is typically initiated for COPD patients with chronic hypoxemia, usually when SpO₂ is less than 88-90%. An SpO₂ of 92% may not necessarily require oxygen therapy unless the patient is experiencing significant symptoms or has other comorbid conditions.
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.
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