Prior to administering pain medication to an adult postoperative client, what information should the practical nurse (PN) obtain? (Select all that apply.)

Height and weight of client prior to admission

Client's pain rating on a scale of 1 to 10

Time of last administration of pain medication

Eﬀectiveness of last pain medication administered

History of pain medication use during the past year

Answer and Explanation

Correct Answer : B,C,D

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Correct Answer is D

Explanation

Choice A rationale:

Tape the tube to the child's cheek. Taping the tube to the child's cheek is not the recommended method for securing a gastrostomy enteral tube. It can cause discomfort and skin irritation for the child. Proper securing methods involve using specialized tube holders or dressings designed for this purpose.

Choice B rationale:

Apply water-soluble lubricant to the site. Rationale: Applying a water-soluble lubricant to the site is not a standard practice for gastrostomy tube care. It is essential to keep the site clean and dry to prevent infection. Lubricants are not typically used in this context.

Choice C rationale:

Attaching an extension tube is related to administering feedings or medications rather than the maintenance and care of the gastrostomy site. Site care focuses on protecting the skin and ensuring cleanliness around the tube insertion area.

Choice D rationale:

Apply a skin barrier protectant to the site. Using a skin barrier protectant helps shield the peristomal skin from irritation and breakdown caused by gastric contents and formula leakage.

A. "We need to check the client's urine output every hour.” B. "Expect the stoma to appear pale until healing is complete.” C. "Expect the client's urine to contain clots for the first 24 hours.” D. "We will keep the client's fluid intake restricted until he is free of pain.”

Correct Answer is A

Explanation

The correct answer is A. "We need to check the client's urine output every hour."

Choice A rationale:

Monitoring urine output every hour is crucial for assessing kidney function and ensuring the urostomy is functioning properly, especially in the immediate postoperative period.

Choice B rationale:

A pale stoma is not an expected finding. A healthy stoma should be pink to red. A pale stoma could indicate inadequate blood supply and needs immediate evaluation.

Choice C rationale:

While some blood or small clots in the urine might be expected shortly after surgery, this is not a standard instruction to give. Any significant or persistent bleeding should be reported and assessed promptly.

Choice D rationale:

Restricting fluid intake is generally not recommended after surgery unless specifically ordered. Adequate hydration is important for recovery and maintaining urinary output.

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Prior to administering pain medication to an adult postoperative client, what information should the practical nurse (PN) obtain? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing site care for a child who has a gastrostomy enteral tube. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is discussing the plan of care of a client who is 4 hr postoperative and has a urostomy with an assistive personnel. Which of the following statements should the nurse include in the discussion?

Correct Answer is A

Explanation

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