Twelve hours following a unilateral total knee replacement, a client reports being unable to sleep because of severe incisional pain. What is the best initial nursing action?

Instruct the client in use of the prescribed patient-controlled analgesia (PCA) pump.

Assist the client in assuming a lateral recumbent position for comfort.

Initiate continuous passive motion (CPM) to relieve muscle spasms.

Apply ice to the incision for twenty minutes prior to joint flexion exercises.

Answer and Explanation

The Correct Answer is A

A. Instructing the client in the use of the PCA pump directly addresses the severe pain by allowing the client to self-administer analgesia as needed, which provides immediate relief and is crucial for effective pain management post-surgery.
B. Assisting the client in changing positions may offer temporary relief but does not address the underlying pain, which should be managed primarily through medication.
C. Initiating CPM is not an appropriate first step for managing severe pain. CPM is used for improving joint mobility and should only be considered after effective pain management is established.
D. Applying ice might provide some temporary relief, but it is not a substitute for effective pain control through medication. Addressing the pain with PCA is the priority.

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Correct Answer is A

Explanation

A. It is essential for the nurse to develop self-awareness of their personal values to avoid imposing these values on the client. As an advocate, the nurse's primary role is to represent the client's wishes and ensure they are respected, regardless of the nurse's personal beliefs or values.
B. While challenging differing opinions may sometimes be necessary, it is more important to ensure the client's wishes are clearly communicated rather than simply opposing differing views.
C. Educating the client on relevant nursing literature is not the primary role of advocacy in this context. The focus should be on the client’s values and wishes rather than on influencing them with professional literature.
D. Listening to discussions is important, but the nurse's role as an advocate is to ensure the client's voice is heard during the discussions, rather than informing the client of decisions after the fact.

A. Impaired bed mobility. B. Fluid volume deficit. C. Bowel incontinence. D. Caregiver role strain.

Correct Answer is B

Explanation

A. Impaired bed mobility is a concern, especially for an immobile client, but addressing fluid volume deficit takes precedence due to its immediate impact on the client's health.
B. Fluid volume deficit is a critical issue, particularly with diarrhea, which can lead to dehydration and electrolyte imbalances. Ensuring adequate fluid intake and managing fluid balance is essential for preventing complications.
C. Bowel incontinence is a significant issue but managing fluid volume deficit is more urgent to prevent potential complications from dehydration.
D. Caregiver role strain is important, but the immediate priority should be addressing the client’s health needs, such as preventing and managing fluid volume deficit, which can impact overall well-being.

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Twelve hours following a unilateral total knee replacement, a client reports being unable to sleep because of severe incisional pain. What is the best initial nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?

Correct Answer is A

Explanation

The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?

Correct Answer is B

Explanation

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

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