A client who had surgery 3 days ago is sitting with head of bed at 75 degrees and requests to be repositioned. Which instruction is most important for the nurse to provide to the unlicensed assistive personnel (UAP)?

Have the client hold a pillow over the abdomen to cough and deep breathe.

Encourage the client to eat all of the meals that are sent.

Offer fruit juice at least twice during both the day and evening shifts.

Lower the bed prior to helping the client to move up in bed.

Answer and Explanation

The Correct Answer is D

Choice A: Have the client hold a pillow over the abdomen to cough and deep breathe is not the most important instruction because it is not related to repositioning. This is a good practice to prevent respiratory complications after surgery, but it can be done at any time.

Choice B: Encourage the client to eat all of the meals that are sent is not the most important instruction because it is not related to repositioning. This is a good practice to promote nutrition and healing after surgery, but it can be done at any time.

Choice C: Offer fruit juice at least twice during both the day and evening shifts is not the most important instruction because it is not related to repositioning. This is a good practice to prevent dehydration and constipation after surgery, but it can be done at any time.

Choice D: Lower the bed prior to helping the client to move up in bed is the most important instruction because it reduces the risk of injury and falls for both the client and the UAP. This is a safety measure that should be done before any repositioning.

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Correct Answer is ["1"]

Explanation

To find the number of tablespoons, the nurse needs to convert the dose from milligrams (mg) to milliliters (mL), and then from milliliters to tablespoons. One tablespoon is equal to 15 mL.

The bottle label shows that 30 mg of dextromethorphan is equivalent to 15 mL of oral suspension. Therefore, the client needs to take 15 mL of oral suspension to get 30 mg of dextromethorphan.

Since one tablespoon is equal to 15 mL, the client needs to take one tablespoon of oral suspension with each dose.

A. Provide comfort measures such as topical warm application and tactile massage. B. Assist the client to ambulate as much as possible during waking hours. C. Determine client's subjective measure of pain using a numerical pain scale. D. Encourage increased fluid intake and measure urinary output every 8 hours. E. Implement a 24-hour schedule of routine administration of prescribed analgesic.

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

Explanation

Choice A Reason: This is correct because providing comfort measures such as topical warm application and tactile massage can help reduce pain perception and promote relaxation by stimulating non-painful sensory receptors.

Choice B Reason: This is incorrect because assisting the client to ambulate as much as possible during waking hours can increase pain intensity and fatigue by aggravating inflamed or injured tissues. The nurse should encourage moderate physical activity within the client's tolerance level.

Choice C Reason: This is correct because determining client's subjective measure of pain using a numerical pain scale can help assess pain severity and effectiveness of pain management interventions. Pain is a subjective experience that varies among individuals.

Choice D Reason: This is incorrect because encouraging increased fluid intake and measuring urinary output every 8 hours are not directly related to pain management. These interventions are more relevant for clients with fluid imbalance or renal impairment.

Choice E Reason: This is correct because implementing a 24-hour schedule of routine administration of prescribed analgesic can help maintain a steady level of analgesia and prevent breakthrough pain. Chronic pain requires continuous treatment rather than on-demand administration.

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A client who had surgery 3 days ago is sitting with head of bed at 75 degrees and requests to be repositioned. Which instruction is most important for the nurse to provide to the unlicensed assistive personnel (UAP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours as needed for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)

Correct Answer is ["1"]

Explanation

After reviewing the admission assessment of a client with chronic pain, which intervention(s) should the nurse include in this client's plan of care? (Select all that apply.)

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

Explanation

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