A client who had orthopedic surgery 3 days ago complains of difficulty sleeping. Which initial intervention is best for the practical nurse (PN) to implement?
Administer a PRN prescription for pain.
Reposition the client and provide a back rub
Offer the client a prescribed sleep medication
Provide a cup of hot chocolate at bedtime
The Correct Answer is B
A. Administer a PRN prescription for pain: While postoperative pain can interfere with sleep, pain medication should be given only after assessing and addressing comfort measures. Nonpharmacologic interventions should be attempted first unless the client reports significant pain.
B. Reposition the client and provide a back rub: Repositioning promotes comfort and improves circulation, while a back rub helps the client relax and may relieve mild muscle tension. These nonpharmacologic measures are safe, promote rest, and are appropriate as an initial nursing intervention for sleep difficulty.
C. Offer the client a prescribed sleep medication: Sedative or hypnotic medications may be necessary for persistent insomnia, but they should not be the first intervention. The nurse should attempt comfort measures before administering pharmacologic sleep aids.
D. Provide a cup of hot chocolate at bedtime: Hot chocolate contains caffeine, which can stimulate the nervous system and interfere with sleep. Offering warm milk or herbal tea would be a better bedtime option, but comfort measures should be prioritized first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Gravida-4, Para-3: Gravida refers to the total number of pregnancies, and this client has been pregnant four times (twins, son, fetal loss, and current pregnancy). As there are 2 children from the twins and 1 child aged 4 the parity is 4. The fetal loss at 24 weeks is not considered viable gestational age.
B. Gravida-5, Para-3: This option incorrectly counts one extra pregnancy. The client has had four total pregnancies (not five), and only two resulted in live births beyond 20 weeks. The fetal loss at 24 weeks does not add to the parity count since the baby was not viable.
C. Gravida-4, Para-4: Gravida 4 accounts for all pregnancies, however since the fetal loss is included in the count, the parity is incorrectly stated as 4
D. Gravida-5, Para-2: This option counts the twin pregnancy as two different pregnancies which is incorrect. Parity of 2 does not account for the twins.
Correct Answer is B
Explanation
A. Compare the client's current vital signs with vital signs taken earlier in the day: Vital signs can provide objective data but may not accurately reflect pain intensity or quality. They cannot replace the client’s subjective report, which is the most reliable indicator of pain.
B. Ask the client to provide a detailed description about the quality of the pain: Obtaining the client’s description allows the PN to validate the presence, severity, and characteristics of pain. This subjective data guides appropriate interventions and ensures individualized pain management.
C. Review the medication record and note when the client last received an analgesic: While reviewing medication timing is important for planning pain relief, it does not confirm whether the client is currently experiencing pain or its intensity.
D. Consult with the charge nurse about the manifestations that the client is exhibiting: Consulting another nurse may be helpful for collaborative care, but first-hand assessment and obtaining the client’s subjective report are necessary before escalation.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.