A nurse is planning to use nonpharmacological pain relief methods for a client who reports continued mild back pain after receiving analgesia 1 hr ago. Which of the following actions should the nurse include in the plan?

Instruct the client to take deep, rhythmic breaths.

Encourage the client to apply a heating pad for 2 hr at a time.

Remove distractions from the client's room.

Apply an ice pack to the client's back for 1 hr.

Answer and Explanation

The Correct Answer is A

A.   Deep breathing is a relaxation technique that can help reduce pain by increasing oxygen delivery, decreasing muscle tension, and promoting a sense of calmness. The nurse should instruct the client to breathe slowly and deeply through the nose and exhale through the mouth.
B.   Heat therapy may provide relief for muscle-related back pain but should not be applied for prolonged periods as it may cause tissue damage.
C.   Minimizing environmental stimuli can help the client focus on relaxation techniques and alleviate pain perception but is not as effective as deep breathing.
D.   Ice therapy is typically used for acute pain or inflammation and may not be appropriate for mild, ongoing back pain.

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Correct Answer is C

Explanation

A. Clean gloves are typically sufficient for wound care, and the use of sterile gloves may not be necessary for routine dressing changes.
B. Frequent dressing changes can disrupt wound healing and increase the risk of infection. Dressings should be changed according to the healthcare provider's instructions, which are typically less frequent.
C. When cleaning the wound, it is important to start from the incision site and work outward to avoid introducing contaminants into the wound.
D. Tincture of benzoin is a skin adhesive and may not be routinely used for dressing changes, especially if it is not specified in the healthcare provider's orders.

A. Hold the dropper 3 cm (1.2 in) away from the client's eye. B. Massage the client's eyelids for 20 seconds after instillation. C. Wait 5 min between the administration of each medication. D. Ask the client to close their eyes tightly after instilling each medication.

Correct Answer is C

Explanation

A. The dropper should be held about 1 cm (0.4 in) away from the eye to avoid touching or injuring the eye or contaminating the dropper tip.
B. Massaging the eyelids after instillation is not a standard practice and may cause discomfort or injury to the eye.
C. Administering multiple ophthalmic medications requires a sufficient interval between doses to prevent interactions and ensure effectiveness.
D. Asking the client to close their eyes tightly may squeeze out some of the medication or increase intraocular pressure.

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A nurse is planning to use nonpharmacological pain relief methods for a client who reports continued mild back pain after receiving analgesia 1 hr ago. Which of the following actions should the nurse include in the plan?

Nursing Test Bank

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Correct Answer is C

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