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 0 to 10. After placing a call to the healthcare provider, which action should the nurse implement?

Provide at least 20 minutes of back massage and gentle efleurage.

Instruct the client to use guided imagery and slow rhythmic breathing.

Place a hot water circulation device, such as an aquathermia pad, on the operative site.

Tune to a television show or easy listening music to provide distraction.

Answer and Explanation

The Correct Answer is A

Choice A reason: Providing a back massage and gentle efleurage can help alleviate pain through relaxation
techniques and is a non-pharmacological method to manage pain.

Choice B reason: Guided imagery and slow rhythmic breathing are helpful relaxation techniques, but they may not be as immediately effective for incisional pain as direct physical interventions.

Choice C reason: The use of a hot water circulation device should be done with caution postoperatively, as it may not be appropriate depending on the surgical site and the client's condition.

Choice D reason: Distraction techniques like watching television or listening to music can be helpful, but they may not address the physical component of the client's incisional pain.

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Correct Answer is C

Explanation

Choice A reason: Using normal saline to irrigate the wound is a correct practice and does not indicate a need for additional teaching. Normal saline is isotonic and is commonly used for wound irrigation because it does not interfere with the natural healing process.

Choice B reason: Cleaning from less soiled to more soiled areas is also a correct technique to prevent contamination of cleaner areas. This method helps to reduce the risk of infection and is a standard practice in wound care.

Choice C reason: Opening a sterile package towards the body is incorrect and indicates that additional teaching is needed. When opening a sterile package, it should be opened away from the body to maintain the sterility of the contents and prevent contamination.

Choice D reason: Placing soiled dressing in a plastic bag is a proper disposal method and does not indicate a need for additional teaching. It is important to properly dispose of soiled dressings to prevent the spread of infection.

A. Drink 800 to 1,000 milliliters of fluid daily. B. Take oxycodone as scheduled to prevent painful bowel movements. C. Add fat-containing foods in the diet to lubricate stools for easier passage. D. Ambulate early and as frequently as possible.

Correct Answer is D

Explanation

Choice A reason: Drinking 800 to 1,000 milliliters of fluid daily is below the recommended intake for most adults, which is generally around 2,000 milliliters per day to help prevent constipation.

Choice B reason: Oxycodone is an opioid that can actually lead to constipation, and its use should be carefully managed, not necessarily taken as scheduled for this purpose.

Choice C reason: Adding fat-containing foods is not a standard recommendation for preventing constipation; instead, a high-fiber diet is usually advised.

Choice D reason: Early and frequent ambulation is encouraged postoperatively to help stimulate bowel function and prevent constipation.

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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 0 to 10. After placing a call to the healthcare provider, which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A family member is demonstrating wound care using sterile technique. Which action indicates to the nurse that additional teaching is needed?

Correct Answer is C

Explanation

The nurse is providing postoperative teaching to a client on ways to prevent constipation. Which information should the nurse include?

Correct Answer is D

Explanation

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