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 ["A","B","C"]
Explanation
Her fasting 1-hour glucose screening level, which was done 1 week prior, is 164 mg/dl. (9.1 mmol/L) Her 3-hour oral glucose tolerance test results reveal a fasting blood sugar of 168 (9.3 mmol/L) and a two-hour postprandial of 220 mg/dL (12.2 mmol/L).
The client has gestational diabetes mellitus (GDM), which is a condition that affects some pregnant women and causes high blood sugar levels. This is bad during pregnancy because it can increase the risk of complications for both the mother and the baby, such as preeclampsia, macrosomia, birth trauma, neonatal hypoglycemia, and congenital anomalies. The client needs to follow a diet and exercise plan to control her blood sugar levels and prevent further complications. She may also need to take insulin injections or oral medications if diet and exercise are not enough. The client should monitor her blood sugar levels regularly and report any abnormal results to her health care provider. The client should also have regular prenatal visits and ultrasounds to check the growth and development of the baby.
Correct Answer is ["A","B"]
Explanation
The correct answer is a. Inspect skin for redness and b. Use a residual limb shrinker.
Choice A rationale:
Inspecting the skin for redness is crucial to identify any signs of infection or pressure sores early. Redness can indicate irritation or the beginning of a pressure ulcer, which needs to be addressed promptly to prevent further complications.
Choice B rationale:
Using a residual limb shrinker helps to reduce swelling and shape the residual limb for prosthetic fitting. It also helps in managing pain and promoting healing by providing consistent compression.
Choice C rationale:
Avoiding range of motion exercises is incorrect. Range of motion exercises are essential to maintain joint flexibility and prevent contractures, which can hinder the use of a prosthetic limb.
Choice D rationale:
Applying alcohol to the residual limb after bathing is not recommended. Alcohol can dry out the skin and cause irritation, which can lead to skin breakdown and infection. Instead, the residual limb should be kept clean and moisturized with appropriate skin care products.
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