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 ["40"]
Explanation
To determine the amount of mL the child should receive per day, we need to calculate the total daily dose of ampicillin based on the prescription.
The prescription is for 500 mg of ampicillin four times a day, so the total daily dose is: 500 mg × 4 times = 2000 mg/day
The concentration of the suspension is 250 mg/5 mL, which means that there are 250 mg of ampicillin in every 5 mL.
To find out how many mL the child should receive per day, we divide the total daily dose by the concentration:
2000 mg ÷ 250 mg/5 mL = 40 mL/day
Therefore, the child should receive 40 mL of the ampicillin suspension per day.
Correct Answer is A
Explanation
The excoriated and red skin in the diaper area suggests the presence of diaper dermatitis, which is commonly caused by prolonged exposure to moisture and irritants such as urine and feces. Changing the diaper more frequently helps to minimize the exposure to these irritants and promotes better skin hygiene.
Asking the mother to decrease the infant's intake of fruits for 24 hours is not necessary unless there is evidence of diarrhea or specific dietary concerns. Fruits are generally a healthy part of an infant's diet and do not directly cause diaper dermatitis.
Encouraging the mother to apply lotion with each diaper change may not be recommended in this case, as lotions and creams can further trap moisture and exacerbate the condition. It is best to keep the area clean and dry.
Telling the mother to cleanse with soap and water at each diaper change may be too harsh for the infant's sensitive skin. Plain water or mild, fragrance-free wipes are typically sufficient for cleaning the diaper area. Soap can be drying and irritating to the skin, so it is generally not necessary unless there is a specific indication.
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