One hour after arriving on the postoperative unit, a woman who received spinal anesthesia 5 hours ago is complaining of severe abdominal incisional pain. Her vital signs are: temperature 99° F (37.2° C), heart rate 110 beats/minute, respiratory rate 30 breaths/minute and blood pressure 160/90 mmHg. The client's skin is pale, and the surgical dressing is dry and Intact. Which intervention is most important for the nurse to Implement?
Provide pillow for splinting.
Assess the IV site for patency.
Place in a high Fowler position.
Administer an IV analgesic.
The Correct Answer is B
The client is experiencing severe abdominal incisional pain, and her vital signs indicate an elevated heart rate, respiratory rate, and blood pressure. These signs suggest that the client is in distress and may be experiencing pain-related complications.
Assessing the IV site for patency is crucial to ensure that the client is receiving the prescribed IV analgesic medication effectively. If the IV site is not patent or if there is any obstruction, the administration of IV analgesics may be delayed, resulting in inadequate pain relief for the client.
While providing a pillow for splinting can offer comfort and support to the client, it is not the most critical intervention in this situation. Placing the client in a high Fowler position may help with pain management, but it is not the priority at this moment. Administering an IV analgesic is an appropriate intervention, but before doing so, it is essential to ensure that the IV site is patent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Administering a large volume of medication in a single injection is not recommended for infants as it can lead to discomfort, tissue trauma, and potential complications such as muscle fibrosis or nerve injury. Dividing the medication into two injections with volumes under 1 mL is a common practice for infants and can help minimize discomfort and complications.
In addition, the nurse should select an appropriate needle size and injection site based on the infant's size and age. A 22 gauge 1 1/2 inch (3.8 cm) needle is too large for an infant and may cause discomfort and tissue damage. The nurse should use a smaller gauge needle and choose an appropriate injection site, such as the vastus lateralis muscle in the thigh or the dorsogluteal muscle in the buttocks, based on the infant's age and size.
Finally, administering an injection into the deltoid muscle is not recommended for infants as this muscle is not fully developed until later in childhood. Using a quick dart-like motion to inject into the dorsogluteal site is also not recommended as it can cause tissue damage and discomfort. Instead, the nurse should use a slow, steady technique to administer the injection while ensuring the infant is held securely by the parent or another caregiver.
Correct Answer is ["B","C","D"]
Explanation
A) Incorrect- Standard precautions are used for all clients to prevent the spread of infections.
However, in the case of MRSA, contact precautions are needed due to the risk of direct transmission through physical contact.
B) Correct- Monitoring the white blood cell count is important to assess for signs of infection, as an elevated count might indicate an ongoing inflammatory response.
C) Correct- Foul-smelling drainage from an incision with suspected MRSA indicates a potential infection. Contact precautions are appropriate for MRSA, which include wearing gloves and gowns when entering the client's room to prevent the spread of the bacteria.
D) Correct- Sending wound drainage for culture and sensitivity helps identify the specific microorganisms causing the infection and guides appropriate antibiotic treatment.
E) Incorrect- A low-bacteria diet is not relevant to the situation. MRSA is caused by a bacterium, not by dietary factors. The focus should be on infection control measures and appropriate medical interventions.
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