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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","C","E"]

Explanation

Choice A reason: Reorienting to day and time frequently is a nursing intervention that the nurse should implement, because it can help the client to reduce confusion, anxiety, and disorientation, which may contribute to the auditory hallucinations. The nurse should use simple and clear language, speak slowly and calmly, and provide cues and reminders, such as a clock, a calendar, or a picture, to help the client to orient to reality.

Choice B reason: Applying soft wrist restraints bilaterally is not a nursing intervention that the nurse should implement, unless it is absolutely necessary and ordered by the doctor. Restraints can increase the client's agitation, anxiety, and fear, and they can also cause physical and psychological harm, such as skin breakdown, nerve damage, or loss of dignity. The nurse should use restraints only as a last resort, after trying other less restrictive alternatives, such as verbal de-escalation, distraction, or medication.

Choice C reason: Administering a PRN dose of lorazepam is a nursing intervention that the nurse should implement, if it is prescribed by the doctor and indicated by the client's condition. Lorazepam is a benzodiazepine that can help the client to relax, reduce anxiety, and sedate the central nervous system, which may alleviate the auditory hallucinations. The nurse should monitor the client's vital signs, level of consciousness, and respiratory status, and report any adverse effects, such as hypotension, bradycardia, or respiratory depression.

Choice D reason: Turning the television on for distraction is not a nursing intervention that the nurse should implement, because it can worsen the client's auditory hallucinations, confusion, and agitation. The television can provide too much stimulation, noise, and information, which can overload the client's sensory perception and interfere with their ability to distinguish reality from hallucination. The nurse should provide a quiet and calm environment, and limit the sources of auditory input.

Choice E reason: Presenting a calm, supportive demeanor is a nursing intervention that the nurse should implement, because it can help the client to feel safe, comfortable, and respected, and to establish a trusting relationship with the nurse. The nurse should show empathy, compassion, and patience, and avoid arguing, criticizing, or dismissing the client's hallucinations. The nurse should acknowledge the client's feelings, validate their distress, and reassure them that they are not alone.

A. Demonstrate the use of visual scanning during meals to the client and family. B. Explain that weight loss will be reversed after the acute phase of the stroke has ended. C. Suggest that the family bring foods from home that the client enjoys eating. D. Encourage the family to offer to feed the client when she does not eat her entire meal.

Correct Answer is A

Explanation

Choice A reason: Demonstrating the use of visual scanning during meals can help the client overcome the difficulty with visual perception, which is a common problem after a CVA. Visual perception is the ability to interpret and process the information received from the eyes. A CVA can damage the parts of the brain that are responsible for visual perception, causing impairments such as hemianopia, neglect, or agnosia. Visual scanning is a technique that involves moving the eyes or the head from side to side to scan the entire visual field and compensate for the missing or distorted information. Visual scanning can help the client see all the food on the tray and eat more adequately.

Choice B reason: Explaining that weight loss will be reversed after the acute phase of the stroke has ended is not a helpful response to the family's concern, as it does not address the current issue of the client's nutritional status. Weight loss is a common complication of CVA, due to factors such as dysphagia, anorexia, depression, or medication side effects. Weight loss can affect the client's recovery, immunity, and quality of life. Weight loss may or may not be reversed after the acute phase of the stroke, depending on the client's condition, treatment, and rehabilitation.

Choice C reason: Suggesting that the family bring foods from home that the client enjoys eating is not a sufficient response to the family's concern, as it does not address the underlying cause of the client's poor intake. The client's difficulty with visual perception may prevent her from seeing or recognizing the food, regardless of whether it is from the hospital or from home. The family should also consider the client's dietary restrictions, allergies, and preferences before bringing any food from home.

Choice D reason: Encouraging the family to offer to feed the client when she does not eat her entire meal is not an appropriate response to the family's concern, as it may undermine the client's autonomy and dignity. The client's difficulty with visual perception may not affect her ability to feed herself, as long as she can see the food and the utensils. The family should respect the client's independence and self-care, and only assist her when necessary. The family should also avoid forcing or coaxing the client to eat more than she wants, as this may cause discomfort or resentment.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","C","E"]

Explanation

An older client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. The client's family expresses concern about the client's nutritional status. How should the nurse respond to the family's concern?

Correct Answer is A

Explanation

The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

An older client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan?

The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action about skin care indicates a need for further teaching?

During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

A client with metastatic cancer reports a pain level of 10 on a pain scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which intervention is most important for the nurse to include in this client’s plan of care?

The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?

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?