A nurse is caring for a client who is 1-day postoperative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first?
Ask the client to rate her pain on a scale from 0 to 10.
Reposition the client and offer her a back rub.
Determine the time the client last received pain medication.
Measure the client's vital signs, including temperature.
The Correct Answer is A
A) Ask the client to rate her pain on a scale from 0 to 10:
Assessing the client's pain intensity is the first essential step in managing postoperative pain. Understanding the severity of pain will guide the nurse in determining the appropriate intervention and whether immediate pain relief measures or further assessment are needed.
B) Reposition the client and offer her a back rub:
Repositioning and providing comfort measures like a back rub can help alleviate discomfort, but assessing the pain level first is crucial to prioritize interventions effectively.
C) Determine the time the client last received pain medication:
Knowing the timing of the last pain medication dose is important but assessing current pain intensity takes precedence to determine if the client needs immediate pain relief.
D) Measure the client's vital signs, including temperature:
While vital signs are important for overall assessment, addressing pain management and comfort should be the initial focus after the client reports incisional pain postoperatively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["25"]
Explanation
Calculating IV Drip Rate for Manual Infusion
Here's how to calculate the drip rate for the manual IV infusion:
Identify total volume and infusion time:
Total volume of saline solution (NS) to infuse: 100 mL
Infusion time: 4 hours
Convert infusion time to minutes:
4 hours x 60 minutes/hour = 240 minutes
Determine the drip factor:
Drip factor: 60 gtt/mL (indicates the number of drops delivered per milliliter of solution by the IV tubing)
Calculate the desired flow rate (mL/min):
We want to know how many milliliters the nurse needs to infuse per minute.However, the question asks for the rate in gtt/min. We'll calculate the mL/min rate first and then convert it to gtt/min.
Flow rate (mL/min) = Total volume (mL) / Infusion time (minutes)
Flow rate (mL/min) = 100 mL / 240 minutes
Flow rate (mL/min) = 0.4167 mL/min (round to four decimal places for accurate conversion)
Convert mL/min to gtt/min:
Flow rate (gtt/min) = Flow rate (mL/min) x Drip factor (gtt/mL)
Flow rate (gtt/min) = 0.4167 mL/min x 60 gtt/mL
Flow rate (gtt/min) = 25 gtt/min (round to nearest whole number)
Therefore, the nurse should set the manual IV infusion to deliver approximately 25 gtt/min.
Correct Answer is D
Explanation
A) To provide analgesia:
Aspirin is primarily used as an antiplatelet medication in the context of myocardial infarction (MI) and coronary artery disease (CAD). While aspirin can provide mild pain relief (analgesia), its main therapeutic effect in this scenario is not for pain management.
B) To reduce inflammation:
Aspirin does have anti-inflammatory properties, but its use in preventing cardiovascular events like myocardial infarction is primarily due to its antiplatelet effects rather than its anti-inflammatory properties.
C) To prevent fever:
Aspirin is sometimes used to reduce fever, but its role in preventing cardiovascular complications like clot formation after myocardial infarction is more crucial and unrelated to fever prevention.
D) To prevent blood clotting:
Aspirin inhibits platelet aggregation and reduces the risk of blood clot formation. This antiplatelet effect is beneficial in preventing further clot formation in coronary arteries, which is critical in the management of myocardial infarction and coronary artery disease.
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