A nurse is caring for a client who is 24 hours postoperative following abdominal surgery. The client received an opioid analgesic 1 hour ago and now reports a pain level of 2 on a scale of 0 to 10. Which of the following actions should the nurse take?
Administer an additional dose of pain medication.
Maintain the client on bed rest.
Apply a warm, moist compress to the incision area.
Reposition the client.
The Correct Answer is D
Choice A reason: An additional dose of pain medication is not necessary as the client reports a low pain level of 2, indicating effective pain control.
Choice B reason: Maintaining the client on bed rest is not required unless specified by the postoperative care plan. It is generally beneficial to mobilize the client as soon as possible to prevent complications.
Choice C reason: A warm, moist compress may be applied to the incision area if there is specific discomfort or as per the care plan, but it is not indicated solely based on the pain level reported.
Choice D reason: Repositioning the client can help alleviate discomfort and prevent pressure ulcers. It is a suitable action given the low pain level reported.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Increasing the IV flow rate may be necessary if the blood pressure is significantly lower than the preoperative value and there are signs of hypovolemia.
Choice B reason: Reassuring the client is important, but it should not be the first action before assessing the clinical significance of the blood pressure reading.
Choice C reason: Comparing the current blood pressure with the preoperative value helps determine the next steps in management and whether the change is within expected limits.
Choice D reason: Covering the client with a warm blanket may be appropriate if the client is feeling cold, but it is not the first action to take in response to the blood pressure reading.
Correct Answer is A
Explanation
Choice A reason: Sitting in a straight-backed chair helps maintain proper posture and alignment, which is important after hip arthroplasty to prevent dislocation.
Choice B reason: Cleansing the surgical incision with hydrogen peroxide is not recommended as it can be too harsh and impede healing.
Choice C reason: Performing range of motion by adducting the hip is not recommended immediately postoperative as it can increase the risk of dislocation.
Choice D reason: Applying moist heat to the incision while in bed is not recommended as it can increase the risk of infection and delay healing.
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