A nurse is caring for a client who requests pain medication. Which of the following actions should the nurse perform first?

Administer the medication.

Review the effects of the pain medication.

Determine the location of the pain.

Reposition the client.

Answer and Explanation

The Correct Answer is C

A. Administering pain medication should be done after assessing the pain to ensure appropriate treatment.

B. Reviewing the effects of the pain medication is important but should be done after determining the specifics of the pain.

C. The first step in pain management is to assess the pain, including its location, intensity, and characteristics, to ensure that the appropriate treatment is provided.

D. Repositioning the client might help alleviate pain, but it should be considered after assessing the pain.

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Correct Answer is B

Explanation

A. The incentive spirometer should typically be used more frequently, often every 1-2 hours while awake, rather than every 4 hours.

B. Inhaling deeply and holding the breath for a few seconds (often 5-10) is a common recommendation for effective use of the incentive spirometer to maximize lung expansion.

C. The client should be in a sitting position or at a 45-degree angle for optimal use, not just 30 degrees.

D. The recommended breath hold time is usually around 5-10 seconds, not 7 seconds, depending on the specific guidelines provided by the healthcare team.

A. Allow the wound to air periodically. B. Initiate protective isolation. C. Perform hand hygiene prior to dressing changes. D. Clean the incision with soap and water.

Correct Answer is C

Explanation

A. Allowing the wound to air periodically is not recommended as it can expose the incision to potential contaminants.

B. Protective isolation is not typically necessary unless the client is immunocompromised or has an infection.

C. Performing hand hygiene before dressing changes is one of the most important measures to prevent infection by reducing the risk of introducing pathogens to the wound.

D. Cleaning the incision with soap and water is generally not recommended; usually, a specific antiseptic solution is used as directed by the surgeon.

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A nurse is caring for a client who requests pain medication. Which of the following actions should the nurse perform first?

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A nurse is caring for a client who requests pain medication. Which of the following actions should the nurse perform first?