A nurse is caring for a postoperative patient.
When helping to manage the patient’s pain, which of the following principles should the nurse apply? (Select all that apply)
Expect the patient to express his pain both verbally and nonverbally
Administer opioids with caution because they will eventually lead to addiction
Consider the patient’s individual expression of pain
Use a scale from 0 to 10 to monitor the severity of the patient’s pain
Correct Answer : A,C,D
Choice A rationale
Pain is a subjective experience and can be expressed both verbally and nonverbally. It is important for the nurse to be attentive to both types of expressions to effectively manage the patient’s pain.
Choice B rationale
While it is true that opioids should be used with caution due to the risk of addiction, this statement can be misleading. Opioids are often necessary for managing postoperative pain, and the risk of addiction is low when they are used appropriately and under medical supervision.
Choice C rationale
Considering the patient’s individual expression of pain is crucial in pain management. Pain is a subjective experience and can vary greatly between individuals. Tailoring pain management strategies to the individual patient can improve pain control.
Choice D rationale
Using a pain scale is a common and effective way to monitor the severity of a patient’s pain. It provides a quantifiable measure of pain that can be used to guide treatment decisions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"C"}}
Explanation
• Increase fiber intake: This is nonessential at this time. While a high-fiber diet can help prevent future episodes of diverticulitis, it won’t help in the acute phase, especially when the client is unable to eat or drink without vomiting.
• CT of the abdomen with contrast: This is an anticipated action. A CT scan can help confirm the diagnosis of diverticulitis and assess the severity of the condition.
• Flexible sigmoidoscopy: This is an anticipated action. A flexible sigmoidoscopy can help visualize the diverticula and assess the extent of the inflammation.
• Change IV fluids to 0.9% sodium chloride with KCl: This is an anticipated action. The client is likely dehydrated due to vomiting and unable to take oral fluids, so IV hydration is necessary. The client’s potassium level is at the lower end of the normal range, so adding KCl to the IV fluids can help prevent hypokalemia.
• Type and crossmatch blood: This is an anticipated action. The client has a positive stool occult blood test and a lower than normal hemoglobin and hematocrit, suggesting that he may be experiencing bleeding. It’s important to have blood ready for a transfusion if necessary.
• Administer IV piperacillin-tazobactam: This is contraindicated. Piperacillin-tazobactam is a penicillin-based antibiotic, and the client has a known allergy to penicillin. Another class of antibiotics should be used. Please note that these are potential actions and the healthcare provider should be informed immediately for further evaluation and management. It’s important to continue following the provider’s prescriptions and closely monitor the client’s condition.
Correct Answer is D
Explanation
Choice A rationale
Removing the protective gown before exiting the patient’s room is a standard practice in infection control. However, it is not the most critical action when caring for a client with Clostridioides difficile under contact precautions.
Choice B rationale
Utilizing an electronic thermometer to measure the client’s temperature is a routine part of patient care and is not specific to contact precautions for Clostridioides difficile.
Choice C rationale
Shaking bed linens before placing them in a linen bag can potentially spread Clostridioides difficile spores, increasing the risk of transmission.
Choice D rationale
Taking off the protective gown prior to removing gloves is the correct sequence for doffing personal protective equipment (PPE). This sequence is important to prevent the spread of Clostridioides difficile to the healthcare provider and other patients.
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