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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The patient with a recent abdominal incision has an abdominal binder applied. The nurse explains that this appliance helps reduce pain by: The correct answer is choice A: supporting surface and internal tissues.

Choice A rationale:
An abdominal binder is primarily used to support surface and internal tissues. It provides gentle compression and support to the abdominal area, which can reduce pain and discomfort. By holding the incision site together and supporting the surrounding tissues, it can minimize movement and strain on the incision, helping to alleviate pain.
Choice B rationale:
While an abdominal binder may indirectly contribute to back support by stabilizing the abdominal area, its primary purpose is to support the surgical site. Enhancing early ambulation is more related to patient mobility and not the primary purpose of the binder.
Choice C rationale:
Abdominal binders do not increase warmth to the incision site. In fact, excessive warmth can lead to sweating and moisture, potentially increasing the risk of infection. The primary purpose is to provide support.
Choice D rationale:
An abdominal binder does not keep sutures and staples in place. The sutures and staples are used to secure the incision, and the binder is placed over them to provide support and compression. However, the binder itself is not responsible for keeping sutures and staples in place. .

A. increasing pain over several hours. B. an itchy red rash on the skin. C. confusion and inability to walk normally. D. headache and nausea.

Correct Answer is C

Explanation

Choice A rationale:
Increasing pain over several hours is not a typical sign of a fentanyl patch overdose. Fentanyl is a potent opioid, and overdose symptoms often involve respiratory depression, altered mental status, and other serious issues. While it is possible for a patient to experience increased pain if the fentanyl patch is not providing adequate pain relief, this is not a specific sign of overdose.
Choice B rationale:
An itchy red rash on the skin is not a sign of a fentanyl patch overdose but can be associated with skin irritation or allergies to the adhesive in the patch. It's important to differentiate between a skin reaction and an overdose when evaluating patients using fentanyl patches. Overdose symptoms are more severe and life-threatening.
Choice C rationale:
Confusion and the inability to walk normally are characteristic signs of a fentanyl patch overdose. Fentanyl is a potent opioid, and overdose can lead to central nervous system depression, resulting in confusion, altered mental status, and difficulty with coordination and walking. These symptoms are serious and require immediate medical attention.
Choice D rationale:
Headache and nausea are not specific signs of a fentanyl patch overdose. While opioid overdose can cause various symptoms, such as respiratory depression and altered mental status, headache and nausea are not among the primary indicators. However, individual responses to medications can vary, and some patients may experience these symptoms as part of a broader set of overdose signs.

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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.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The patient with a recent abdominal incision has an abdominal binder applied. The nurse explains that this appliance helps reduce pain by:.

Correct Answer is A

Explanation

Signs of fentanyl patch overdose are:.

Correct Answer is C

Explanation

The nurse outlines the four phases of nociceptive pain as: (Select all that apply.).

Kathy is working in a mother-baby unit. Which pain scale is used to determine if the baby is in pain?

IM injections of pain medication may be contraindicated for patients who:.

Going to bed hungry or overly full does not interfere with sleep. It helps the patient reach REM state of sleep faster.

A sleeping patient has periodic pauses in breathing, then starts to breathe again.The nurse recognizes this sleep pattern is consistent with:.

A natural supplement that can enhance sleep for many people is:.

A patient experiencing pain states that guided imagery has made the pain more manageable in the past.To assist this patient, the nurse should:.

A nurse is assisting in the care of a patient who is receiving pain medication by the epidural route.It is most important to monitor this patient for which adverse drug effects?