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 D
Explanation
The correct answer is choice D, Describe the food placement as though the plate were a clock. When delivering the client's meal tray, the nurse should describe the food placement as though the plate were a clock to help the client know where the food is located. This helps the client be more independent and participate actively at mealtime. Choice A is incorrect because arranging for assistive personnel to feed the client may take away the client's independence. Choice B is incorrect because discouraging conversations during the client's mealtime may make the client feel isolated. Choice C is incorrect because providing the client with small-handled adaptive utensils may not help the client locate food on the plate.
Other choices:
A. Arrange for assistive personnel to feed the client: Arranging for assistive personnel to feed the client may take away the client's independence.
B. Discourage conversations during the client's mealtime: Discouraging conversations during the client's mealtime may make the client feel isolated.
B. Provide the client with small-handled adaptive utensils: Providing the client with small-handled adaptive utensils may not help the client locate food on the plate.
Correct Answer is A
Explanation
The correct answer is choice A, Perform suctioning. Restlessness and crackles in the lungs may indicate respiratory distress or airway obstruction, which may be due to mucus or secretions blocking the tracheostomy tube. Performing suctioning helps clear the airway of secretions, which will improve the client's breathing. Choice B is incorrect because instilling saline into the tubing is not a common intervention for managing restlessness and crackles. Choice C is incorrect because checking the cuff pressure is not related to managing restlessness and crackles. Choice D is incorrect because increasing humidification is not a common intervention for managing restlessness and crackles.
Other choices:
Instill saline into the tubing: Instilling saline into the tubing is not a common intervention for managing restlessness and crackles.
Check the cuff pressure: Checking the cuff pressure is not related to managing restlessness and crackles.
Increase the humidification: Increasing humidification is not a common intervention for managing restlessness and crackles.
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