A nurse is caring for a client who is 24 hr postoperative following abdominal surgery. The client received an opioid analgesic 1 hr 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?
Maintain the client on bed rest.
Apply a warm, moist compress to the incision area.
Administer an additional dose of pain medication.
Reposition the client.
The Correct Answer is D
Answer is: d. Reposition the client.
Explanation: Repositioning the client can help alleviate pain by redistributing pressure and promoting comfort. Since the client's pain level is relatively low (2 on a scale of 0 to 10), this non-pharmacological intervention is an appropriate initial action.
Choice a. is wrong because maintaining the client on bed rest is not an appropriate action for a pain level of 2. Instead, the nurse should encourage the client to mobilize and perform appropriate exercises to prevent complications related to immobility.
Choice b. is wrong because applying a warm, moist compress to the incision area might not be the best action for a client who is 24 hours postoperative, as it could increase the risk of infection and cause discomfort. Cold compresses are often used in the initial postoperative period to reduce swelling and promote comfort.
Choice c. is wrong because administering an additional dose of pain medication is not necessary at this point, as the client's pain level is relatively low. The nurse should consider non-pharmacological interventions first and reassess the client's pain level to determine the need for further pain relief.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Lime ice popsicle.
Choice A rationale:
Orange juice is acidic and can irritate the stomach lining, which is not ideal for someone recovering from gastroenteritis.Acidic foods and drinks can exacerbate symptoms like nausea and stomach pain.
Choice B rationale:
Cream of broccoli soup is not recommended because it is a dairy-based product.Dairy can be difficult to digest and may worsen symptoms like diarrhea and stomach cramps during the recovery phase of gastroenteritis.
Choice C rationale:
Lime ice popsicle is a good choice because it is a clear liquid that can help with hydration and is easy on the stomach.Ice popsicles can also help soothe the throat and provide a small amount of sugar for energy without overwhelming the digestive system.
Choice D rationale:
Vanilla pudding, although soft, contains dairy, which can be hard to digest for someone recovering from gastroenteritis.Dairy products can lead to further gastrointestinal discomfort.
Correct Answer is D
Explanation
The correct answer is choice D. The nurse should identify an oral temperature of 39°C (102.2°F) as the priority finding in a client who is postoperative following a total thyroidectomy for hyperthyroidism. An elevated temperature can indicate infection, which is a risk after surgery. The nurse should report this finding to the provider immediately.
Choices A, B, and C are incorrect because moderate amount of serosanguineous drainage on dressings, serum calcium level 9.2 mg/dL, and report of a sore throat, respectively, are expected findings after a total thyroidectomy and do not require immediate action.
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