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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) "Take the medication on an empty stomach":
Taking baclofen with food can help reduce gastrointestinal side effects such as nausea. However, the instruction to take it on an empty stomach is not necessary or typically recommended. Ensuring consistent timing with or without food is more practical for adherence and reducing potential side effects.
B) "Stop taking the medication immediately for headache":
While headaches can be a side effect of baclofen, stopping the medication abruptly can lead to withdrawal symptoms or worsening of muscle spasticity. It's important to discuss any persistent or severe headaches with the healthcare provider to determine the appropriate management.
C) "Diarrhea is an adverse effect of this medication":
Diarrhea can indeed be a side effect of baclofen, but it is not one of the primary or most common side effects. Constipation is actually more frequently observed. Monitoring for gastrointestinal changes and discussing them with the healthcare provider is important for appropriate management.
D) "Avoid driving until the medication's effects are evident":
This instruction is crucial because baclofen can cause drowsiness or dizziness, especially when starting the medication or when the dosage is adjusted. It is important for the client to avoid activities such as driving until they are aware of how the medication affects them to ensure safety.
Correct Answer is A
Explanation
A) "Apply the ointment in a thin line into the conjunctival sac":
This instruction is correct for applying ophthalmic ointments. Placing the ointment in a thin line along the conjunctival sac ensures proper distribution and contact with the affected area.
B) "Keep your eye open for 30 sec after instilling the ointment":
Keeping the eye open for a brief period after instillation helps the ointment spread across the eye surface. This statement indicates understanding of the proper technique for applying ophthalmic ointments and does not require further instruction.
C) "Use a sterile glove and applicator to apply the antibiotic ointment":
Using a sterile glove and applicator ensures that the application is done in a sterile manner, reducing the risk of introducing further infection. This statement indicates a need for further instruction, as ophthalmic ointments are typically applied using clean hands or disposable, sterile applicators rather than sterile gloves.
D) "Always wipe from the outer to the inner canthus when wiping away secretions":
Wiping from the outer to the inner canthus helps prevent contamination of the unaffected eye. This statement demonstrates understanding of proper eye care techniques and does not require further instruction.
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