The nurse is caring for a client who is still experiencing light sedation after undergoing an emergency colectomy for bowel obstruction. Which postoperative pain intervention should the nurse implement first?

Provide the first medication prescribed for pain management.

Review medical records to obtain pain tolerance expectations.

Wait until the client is awake before providing pain management.

Attempt to obtain a self-report of pain level from the client.

Answer and Explanation

The Correct Answer is A

Choice A reason: Providing the first medication prescribed for pain management is the best intervention that the nurse can implement first, because it can prevent the escalation of pain and reduce the need for higher doses later. The nurse should follow the principles of pain management, such as administering analgesics before pain becomes severe, using a multimodal approach, and individualizing the plan of care.

Choice B reason: Reviewing medical records to obtain pain tolerance expectations is not a priority intervention that the nurse should implement first, because it may not reflect the current pain level or needs of the client. Pain tolerance is influenced by many factors, such as culture, age, gender, and previous experiences, and it may vary from person to person and from situation to situation.

Choice C reason: Waiting until the client is awake before providing pain management is not a recommended intervention that the nurse should implement first, because it can lead to inadequate pain relief and delayed recovery. The nurse should not assume that the client is not in pain because of sedation, but should use other indicators, such as vital signs, facial expressions, and body movements, to assess pain.

Choice D reason: Attempting to obtain a self-report of pain level from the client is not a feasible intervention that the nurse should implement first, because the client may not be able to respond due to sedation. The nurse should use a valid and reliable pain assessment tool that is appropriate for the client's condition, such as the Behavioral Pain Scale (BPS) or the Critical-Care Pain Observation Tool (CPOT), to measure pain.

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Correct Answer is C

Explanation

Choice A reason: An apical heart rate of 100 to 110 beats/minute is not unusual after surgery, as the client may be experiencing stress, pain, or anxiety. This finding does not require immediate action by the nurse, but should be monitored and reported if it persists or worsens.

Choice B reason: Redness and edema at the incision site are expected signs of inflammation and healing after surgery. This finding does not require immediate action by the nurse, but should be assessed for signs of infection, such as pus, warmth, or foul odor.

Choice C reason: A high-pitched sound heard upon inspiration, also known as stridor, is a sign of upper airway obstruction, which can be life-threatening. This finding requires immediate action by the nurse, such as administering oxygen, suctioning, or calling for help.

Choice D reason: A pain rating of 8 on a scale of 1 to 10 indicates severe pain, which can affect the client's recovery and comfort. This finding requires prompt action by the nurse, such as administering analgesics, repositioning, or providing non-pharmacological interventions. However, this is not as urgent as choice C, which involves the client's airway.

A. Use incentive spirometer. B. Monitor urinary stream for decrease in output. C. Report when hematuria becomes pink tinged. D. Restrict physical activities.

Correct Answer is B

Explanation

Choice A reason: Using incentive spirometer is not a relevant instruction for a client with BPH who underwent TUNA. Incentive spirometer is a device that helps improve lung function and prevent respiratory complications after surgery or prolonged bed rest. TUNA is a minimally invasive procedure that uses radiofrequency energy to shrink the prostate tissue and relieve the urinary obstruction. TUNA does not affect the respiratory system or require general anesthesia.

Choice B reason: Monitoring urinary stream for decrease in output is an important instruction for a client with BPH who underwent TUNA. Urinary output can reflect the kidney function and the effectiveness of the procedure. A decrease in urinary output can indicate urinary retention, infection, or bleeding, which are potential complications of TUNA. The client should report any changes in the urinary stream, such as difficulty, pain, frequency, urgency, or hesitancy, to the health care provider.

Choice C reason: Reporting when hematuria becomes pink tinged is not a necessary instruction for a client with BPH who underwent TUNA. Hematuria is the presence of blood in the urine, which is a common and expected finding after TUNA. Hematuria usually resolves within a few days and does not require intervention, unless it is excessive or persistent. The client should drink plenty of fluids to flush out the blood and prevent clot formation. The client should report any signs of infection, such as fever, chills, or foul-smelling urine, to the health care provider.

Choice D reason: Restricting physical activities is a correct instruction for a client with BPH who underwent TUNA. Physical activities can increase the blood pressure and the risk of bleeding or injury to the prostate. The client should avoid strenuous activities, such as lifting, running, or biking, for at least two weeks after the procedure. The client should also avoid sexual intercourse, driving, or sitting for long periods until the symptoms subside. The client should follow the health care provider's advice on when to resume normal activities.

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