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.

Answer and Explanation

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.

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Correct Answer is A

No explanation

A. Monitor for at least 150 mL of drainage every hour. B. Clamp the tube for 30 min every 8 hr. C. Pin the tubing to the client's bed sheets. D. Replace the unit when the drainage chamber is full.

Correct Answer is A

Explanation

Monitor for at least 150 mL of drainage every hour. The nurse should monitor the chest tube drainage for excessive or sudden increases in order to detect any complications, such as pneumothorax. Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications. Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided. The chest tube unit should only be replaced when there is a problem with the unit or the seals.

Choice B: Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications.

Choice C: Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided.

Choice D: The chest tube unit should only be replaced when there is a problem with the unit or the seals.

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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?

Nursing Test Bank

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