The nurse is providing postoperative care for a client who complains of severe pain after receiving codeine 30 mg orally one hour ago.
Which intervention should the nurse implement next?

Ask the UAP to offer back rubs to the client.

Reassess the client and the level of pain.

Encourage the client to focus on taking deep breaths. D. Tell the client the medication needs more time to work.

Holds the crutch 6 inches (15 cm) to the side.

Answer and Explanation

The Correct Answer is B

The nurse should reassess the client’s pain level and determine if additional interventions are needed to manage the pain.

Choice A is not the answer because while a back rub may provide some temporary relief, it does not address the underlying cause of the pain.

Choice C is not the answer because while deep breathing can help with relaxation, it does not address the underlying cause of the pain.

Choice D is not the answer because telling the client that the medication needs more time to work does not address their current pain level or provide any immediate relief.

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Correct Answer is C

Explanation

This will help determine if there is any residual urine left in the bladder after voiding.

Choice A is not the answer because reviewing the chart for the number of voids over the last 24 hours is important but not sufficient to evaluate for urinary retention.

Choice B is not the answer because evaluating for urinary incontinence is important but not sufficient to evaluate for urinary retention.

Choice D is not the answer because while palpating the suprapubic region for distention can provide some information, scanning the bladder after voiding is a more accurate way to evaluate for urinary retention.

A. Blood pressure. B. Respiratory rate. C. Temperature. D. Pulse rate.

Correct Answer is B

Explanation

If a nurse observes that a client is using accessory muscles, it indicates an obstruction of the airways, which reduces oxygen saturation.

Accessory muscles help in the act of forced expiration to wash out carbon dioxide and improve oxygen saturation 1.

Therefore, the nurse should obtain the respiratory rate first.

Choice A is not the answer because determining pulse pressure will not provide any significant indication of respiratory distress 1.

Choice C is not the answer because temperature does not provide any significant data about the use of accessory muscles in respiration 1.

Choice D is not the answer because pulse rate does not provide any significant data about the use of accessory muscles in respiration 1.

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The nurse is providing postoperative care for a client who complains of severe pain after receiving codeine 30 mg orally one hour ago. Which intervention should the nurse implement next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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The nurse is providing postoperative care for a client who complains of severe pain after receiving codeine 30 mg orally one hour ago.
Which intervention should the nurse implement next?