A nurse is caring for a client who is postoperative following a hemicolectomy. Which of the following is a subjective indication that the client needs PRN pain medication?

The client's heart rate is 110/min.

The client is guarding their abdominal incision.

The client exhibits facial grimacing.

The client reports pain.

Answer and Explanation

The Correct Answer is D

The subjective indication that the client needs PRN (as needed) pain medication is when the client reports pain. Pain is a subjective experience, and it is essential to address the client's self-reported pain level and provide appropriate pain management.

Explanation for the other options:

a) The client's heart rate is 110/min: An increased heart rate can be an objective indication of pain, but it is not a subjective indication. Subjective indications are based on the client's self-report or personal experiences.

b) The client is guarding their abdominal incision: Guarding the abdominal incision may suggest discomfort or pain, but it is an objective indication that can be observed by the nurse. Subjective indications focus on the client's self-report.

c) The client exhibits facial grimacing: Facial grimacing can be an objective indication of pain, but it is not a subjective indication. Again, subjective indications are based on the client's self-report or personal experiences.

In this scenario, the most reliable and appropriate indication for administering PRN pain medication is when the client reports pain, as this acknowledges the client's own perception of their pain level.

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Correct Answer is A

Explanation

Answer: A. Pull the auricle upward and outward.

Rationale:

A. Pull the auricle upward and outward:
Pulling the auricle upward and outward is the recommended technique for instilling ear drops in an adult. This method straightens the ear canal, allowing better access for the medication to reach the target area. It is essential for effective delivery and absorption of the otic suspension.

B. Pull the auricle downward and backward:
Pulling the auricle downward and backward is appropriate for children under three years old, as it aligns their shorter and straighter ear canal. In adults, this approach would not straighten the canal sufficiently for optimal medication instillation.

C. Pull the auricle upward and backward:
While pulling the auricle upward and backward can straighten the adult ear canal, the optimal direction to ensure the ear canal is fully open is upward and outward. This position allows the medication to reach deeper parts of the ear canal effectively.

D. Pull the auricle downward and outward:
Pulling the auricle downward and outward is not suitable for adults and does not provide the correct alignment for an adult ear canal. This technique is ineffective in reaching the canal's deeper parts in adult clients, thus limiting the efficacy of the medication.

A. "I should keep my baby rear-facing in the car seat until she is 2 years old." B. "I should place my baby in the car seat at a 90-degree angle." C. "I should position the car seat's retainer clip at the level of my baby's belly button." D. "I should enable the airbag when my baby is in the front seat of the car."

Correct Answer is A

Explanation

Keeping a baby rear-facing in the car seat until they reach the age of 2 years old or until they reach the maximum height and weight limits recommended by the car seat manufacturer is a crucial safety guideline. Rear-facing car seats provide better support for a baby's head, neck, and spine in the event of a crash, reducing the risk of severe injuries.

"I should place my baby in the car seat at a 90-degree angle." The correct positioning for a rear-facing car seat is typically between a 30 to 45-degree angle. This angle helps ensure the baby's airway remains open and prevents their head from flopping forward.

"I should position the car seat's retainer clip at the level of my baby's belly button." The retainer clip of the car seat should be positioned at armpit level, not at the level of the baby's belly button. The retainer clip is designed to secure the harness straps and should be placed across the chest, resting on the bony part of the shoulders.

"I should enable the airbag when my baby is in the front seat of the car." It is not safe to have a rear-facing car seat with a baby in the front seat of a vehicle with an active airbag. Airbags can pose a significant risk to infants due to the force with which they deploy. It is recommended to place a rear-facing car seat in the back seat of the vehicle and disable the airbag in the front passenger seat if the baby needs to ride in the front.

It is important for parents to receive proper education on car seat safety and follow the guidelines set forth by car seat manufacturers, national recommendations, and local laws and regulations.

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A nurse is caring for a client who is postoperative following a hemicolectomy. Which of the following is a subjective indication that the client needs PRN pain medication?

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