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 D

Explanation

A. Verbal analogies can be useful in illustrating points, but they may not fully engage participants in hands-on problem-solving.
B. Positive reinforcement encourages participation, but it is not a problem-solving strategy in itself.
C. Physical demonstrations are helpful for teaching techniques but are less effective for fostering problem-solving abilities.
D. Simulation activities provide a dynamic and interactive way for participants to practice problem-solving. They mimic real-life scenarios, allowing individuals to engage in critical thinking and decision-making, which is especially effective for young adults who learn well through active participation.

A. Instruct the client to use guided imagery and slow rhythmic breathing. B. Place a hot water circulation device, such as an Aqua K pad, to the operative site. C. Tune to a television show or easy listening music to provide distraction. D. Provide at least 20 minutes of back massage and gentle effleurage.

Correct Answer is A

Explanation

A. Guided imagery and slow rhythmic breathing are effective techniques for managing moderate pain and can help reduce the perception of pain by promoting relaxation. These methods can be used in conjunction with pain medication to enhance overall pain management.
B. Applying a hot water circulation device may not be appropriate for postoperative pain, as heat could interfere with healing or cause complications. The focus should be on pain management strategies that are safe for the surgical site.
C. While distraction methods like television or music can help, they are generally less effective for managing moderate pain compared to relaxation techniques and additional pain management strategies.
D. Providing a back massage may not be appropriate immediately after thoracic surgery, as it could cause discomfort or interfere with the surgical site. Effective pain management should prioritize safe and recommended interventions.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which action is most useful for the nurse to include during the teaching session?

Correct Answer is D

Explanation

A client who is 2 days postoperative for thoracic surgery is reporting incisional pain 2 hours after receiving pain medication. The client rates the pain as 5 on a pain scale of 1 to 10. After placing a call to the healthcare provider, which action should the nurse implement?

Correct Answer is A

Explanation

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