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 C
Explanation
A) "Heparin enhances the effects of the warfarin.": This statement is incorrect. Heparin and warfarin work through different mechanisms. Heparin acts quickly by inhibiting clot formation through antithrombin, while warfarin acts slower by inhibiting vitamin K-dependent clotting factors. They do not directly enhance each other's effects.
B) "Both heparin and warfarin work together to dissolve the clots.": This is inaccurate. Neither heparin nor warfarin dissolve existing clots; they prevent new clots from forming and existing clots from growing. The body's natural processes will eventually dissolve the clot.
C) "Heparin will be continued until the warfarin reaches a therapeutic level!": This is correct. Heparin is used initially because it acts quickly. Warfarin takes several days to reach therapeutic levels. Overlapping the two ensures continuous anticoagulation until warfarin is effective.
D) "I will ask the charge nurse to call your provider and get an explanation.": While involving the provider for further explanation can be helpful, it does not directly answer the client’s question. Providing accurate information about the overlapping use of heparin and warfarin is more appropriate in this context.
Correct Answer is D
Explanation
A) Notify the nurse manager:
While it's important to communicate the error to the nurse manager and appropriate supervisors, the immediate priority is to address the client's current condition and ensure their safety.
B) Complete an incident report:
Filling out an incident report is necessary to document the error and ensure proper follow-up and investigation. However, the client's immediate well-being takes precedence.
C) Give the client 15 to 20 g of carbohydrate:
Administering carbohydrates may be necessary if the client is hypoglycemic, but checking the blood glucose level first is essential to confirm the current status and determine the appropriate intervention.
D) Check the client's blood glucose level:
This is the priority action because it allows the nurse to assess the client's current blood glucose level and determine if corrective action, such as administering carbohydrates or further insulin adjustments, is needed to address any potential hypoglycemia resulting from the incorrect insulin dose.
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