A nurse is caring for a client who is postoperative. When helping to manage the client's pain, which of the following principles should the nurse apply? (Select all that apply.).
Use a scale from 0 to 10 to monitor the severity of the client's pain.
Consider the client's individual expression of pain.
Expect the client to express his pain both verbally and nonverbally.
Administer opioids with caution because they will eventually lead to addiction.
To achieve fast-acting pain relief, administer analgesics.
Correct Answer : A,B,E
Choice A rationale:
Using a pain scale from 0 to 10 is a crucial principle in managing a client's postoperative pain. It allows for a standardized assessment of pain severity and helps healthcare providers determine the effectiveness of pain management interventions.
Choice B rationale:
Considering the client's individual expression of pain is essential in providing personalized care. People experience and express pain differently, so tailoring the approach to each client's unique needs is vital for effective pain management.
Choice C rationale:
Expecting the client to express pain both verbally and nonverbally is another important principle in pain management. Some clients may not be able to communicate verbally, so nurses should be attentive to nonverbal cues such as grimacing, restlessness, or changes in vital signs to assess pain.
Choice D rationale:
Administering opioids with caution is a general principle in pain management, but the statement that they will eventually lead to addiction is an oversimplification. While there is a risk of opioid addiction, it is not an absolute certainty, and the benefits of pain relief often outweigh the risks. Therefore, this statement is not entirely accurate.
Choice E rationale:
Administering analgesics for fast-acting pain relief is a valid principle, especially in the postoperative period when the client may be experiencing acute pain. Fast-acting analgesics help alleviate immediate discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
If a patient with a Fentanyl patch is experiencing symptoms like abnormal sleepiness, slurred speech, and unsteadiness when ambulating, it could indicate an overdose or adverse reaction to the Fentanyl. In such cases, the patch should be removed immediately to stop the further absorption of the drug. Wiping off the skin can also help remove any residual medication. This is the correct choice as it addresses the issue at its source.
Choice B rationale:
Applying ice to the skin around the Fentanyl patch is not the appropriate action in this situation. Ice will not counteract the effects of a Fentanyl overdose or adverse reaction. The priority is to remove the patch and seek medical attention.
Choice C rationale:
Elevating the head of the bed and offering coffee or cola may be useful in combating some forms of sleepiness but would not be effective for someone experiencing an overdose or adverse reaction to Fentanyl. This choice does not address the problem's root cause and is not the appropriate action to take.
Choice D rationale:
Putting up the side rails on the bed does not address the issue of Fentanyl patch overdose or adverse reactions. This choice is not relevant to the situation and should not be chosen.
Correct Answer is D
Explanation
Choice A rationale:
Bradycardia, a slow heart rate, is not typically associated with acute pain. In response to pain, the body usually experiences increased heart rate (tachycardia) as part of the stress response.
Choice B rationale:
A decreased respiratory rate is not an expected finding in response to acute pain. Acute pain often leads to increased respiratory rate as the body attempts to manage the pain and stress.
Choice C rationale:
Hypoglycemia, a low blood sugar level, is not a typical physiological response to acute pain. Acute pain is more likely to induce a release of stress hormones, such as cortisol and adrenaline, which can lead to increased blood sugar levels.
Choice D rationale:
Hypertension, or elevated blood pressure, is an expected physiological response to acute pain. Pain activates the body's stress response, leading to increased sympathetic nervous system activity, which can cause vasoconstriction and increased blood pressure. This response helps prepare the body to cope with the pain and stress. Monitoring blood pressure in a client reporting acute pain is essential to assess the impact of pain and determine appropriate pain management strategies.
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