A nurse is reinforcing teaching about the importance of pain management with a client who is postoperative. The client states, "I'm pretty tough and can take a lot of pain." Which of the following responses should the nurse make?

"When the pain interferes with movement, you should rate your pain level as a 4 on a scale from 0 to 10."

"Most people who have this procedure are able to manage without pain medication."

"You can wait until your pain level is 8 or higher on a scale from 0 to 10 before asking for medication."

Short-term pain management can promote healing and prevent complications."

Answer and Explanation

The Correct Answer is D

Postoperative pain management is essential for recovery, as untreated pain can interfere with breathing, mobility, and overall healing. Effective pain control supports early ambulation, deep breathing, and participation in care activities, which helps prevent complications such as pneumonia, atelectasis, and venous thromboembolism. Patient misconceptions about pain tolerance can lead to undertreatment and delayed recovery. Nursing education should focus on the physiological benefits of adequate pain control and safe use of analgesia.

Rationale:
A. Telling the client to rate pain as a specific number when it interferes with movement is not an appropriate therapeutic response. Pain is subjective and should be self-reported by the client rather than guided toward a predetermined threshold. This statement may minimize the client’s experience and does not promote individualized pain management.

B. Stating that most people manage without pain medication is inaccurate and may discourage appropriate pain reporting and treatment. Pain experiences vary widely among individuals, and postoperative pain often requires pharmacologic intervention. This response may reinforce misconceptions and lead to undertreatment of pain.

C. Advising the client to wait until pain reaches 8 or higher before requesting medication is unsafe and inappropriate. Severe pain can trigger physiological stress responses, increase oxygen demand, and delay recovery. Pain should be managed proactively rather than waiting until it becomes severe.

D. Short-term pain management promotes healing by reducing stress responses and allowing the client to participate in early mobilization and respiratory exercises. Adequate pain control improves circulation, decreases muscle tension, and supports recovery. It also helps prevent postoperative complications such as impaired lung expansion and thromboembolism.

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Correct Answer is C

Explanation

Delirium is a sudden change in mental status characterized by confusion, disorientation, and altered attention. It is often reversible and typically caused by an underlying medical condition rather than a primary psychiatric disorder. Common triggers include infections, metabolic imbalances, medications, and acute illness, especially in older adults. Identifying and treating the underlying cause is essential to resolving delirium.

Rationale:
A. Hypersomnia is not a recognized risk factor for delirium, although sleep disturbances may occur as a symptom once delirium develops. Delirium is more commonly associated with acute physiological stressors rather than isolated sleep pattern changes. Therefore, hypersomnia does not directly contribute to its onset.

B. Amyloid plaque is associated with Alzheimer’s disease, which is a chronic neurodegenerative disorder rather than an acute condition. Although dementia increases vulnerability to delirium, amyloid plaque itself is not an acute risk factor. Delirium develops due to sudden physiological disturbances, not long-term structural brain changes alone.

C. Urinary tract infection is a common precipitating factor for delirium, especially in older adults. Infections trigger systemic inflammatory responses that affect brain function, leading to confusion and altered cognition. Even mild infections can significantly impact mental status in vulnerable clients, making this a key risk factor.

D. High cholesterol is a long-term cardiovascular risk factor but is not directly associated with the development of delirium. It contributes to atherosclerosis over time but does not cause acute changes in brain function. Therefore, it is not considered a risk factor for delirium onset.

A. Edema to the area around the incision site B. Serous drainage in the closed suction collection device C. Urine output is 40 mL/hr D. WBC count 8, 000/mm3 (5,000 to 10,000 mm3)

Correct Answer is A

Explanation

Postoperative infections occur when microorganisms invade surgical tissues, leading to localized or systemic inflammatory responses. Early identification is essential to prevent complications such as wound dehiscence, sepsis, or delayed healing. Typical signs include localized redness, swelling, warmth, pain, and purulent drainage. Nurses must differentiate normal postoperative inflammatory responses from abnormal findings suggestive of infection.

Rationale:
A. Edema around the incision site may indicate an early localized inflammatory response consistent with postoperative infection. Mild swelling can be expected after surgery, but increasing or persistent edema accompanied by other signs such as redness, warmth, or tenderness raises concern for infection. This occurs due to increased vascular permeability and immune cell activity in response to invading pathogens.

B. Serous drainage in a closed suction device is a normal expected finding in the early postoperative period. This type of clear or pale yellow fluid reflects plasma leakage from healing tissues and does not indicate infection. Infection would be more likely associated with purulent, foul-smelling, or thick drainage.

C. A urine output of 40 mL/hr is within the normal expected range for an adult postoperative client. Adequate urine output (generally ≥30 mL/hr) indicates sufficient renal perfusion and fluid balance. This finding does not suggest infection but rather appropriate kidney function and hydration status.

D. A white blood cell (WBC) count of 8,000/mm³ falls within the normal reference range of approximately 5,000 to 10,000/mm³. While elevated WBC levels may indicate infection, this value does not suggest leukocytosis. Therefore, it does not support the presence of a postoperative infection in this client.

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Body System	Findings
Cardiovascular	S1,S2, no murmur, bradycardia
Respiratory	decreased respiratory effort, equal chest expansion, bilateral crackles
Neurologic	somnolent
Head, Ears, Eyes, Nose, and Throat(HEENT)	oropharynx clear, mucous membranes moist, pinpoint pupils
Vital Signs	Temperature 37.4°C (99.4°F) Heart rate 58/min Respiratory rate 10min Blood pressure 98/58 mm Hg

A nurse is reinforcing teaching about the importance of pain management with a client who is postoperative. The client states, "I'm pretty tough and can take a lot of pain." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who has delirium. The client is disoriented and restless. Which of the following conditions should then nurse identify as a risk factor for delirium?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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