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.
The Correct Answer is B
This postoperative nursing scenario requires the application of non-pharmacological pain management strategies and safety protocols. Knowledge of gate control theory and surgical contraindications is essential to address breakthrough pain effectively while awaiting provider orders without compromising the integrity of the surgical site.
Choice A rationale: While massage can be soothing, 20 minutes of back massage and effleurage is physically demanding and may not be feasible in an acute care setting. Additionally, positioning a thoracic surgery client for a back massage might cause more incisional discomfort.
Choice B rationale: Guided imagery and slow rhythmic breathing are effective non-pharmacological interventions that reduce the perception of pain by decreasing autonomic nervous system arousal. These techniques empower the client and provide immediate relief without risk of injury to the incision.
Choice C rationale: Applying heat to a fresh surgical site is contraindicated because it increases vasodilation, which can lead to increased edema, bleeding, and potential incision dehiscence. Thermal devices should never be placed directly over a fresh operative site without specific orders.
Choice D rationale: Distraction through television or music can be a helpful adjunct, but it is often less effective than active cognitive-behavioral strategies like guided imagery for a pain level of 5. It serves as a passive intervention rather than an active coping skill.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The presence of soft, formed, and light brown feces is normal and does not preclude testing for occult blood. The nurse should proceed with obtaining the specimen as ordered.
Choice B reason: There is no need to contact the healthcare provider before obtaining the specimen if the stool appears normal and the test for occult blood has been ordered.
Choice C reason: Waiting for observable blood is not necessary for an occult blood test, which is designed to detect blood that is not visible to the naked eye.
Choice D reason: Withholding specimen collection until tarry black stool is observed is not indicated. Tarry black stool can indicate bleeding in the upper gastrointestinal tract, but the test for occult blood is used to detect blood that may not be visible in the stool. Bolded text indicates the correct answers and important information.
Correct Answer is B
Explanation
This postoperative nursing scenario requires the application of non-pharmacological pain management strategies and safety protocols. Knowledge of gate control theory and surgical contraindications is essential to address breakthrough pain effectively while awaiting provider orders without compromising the integrity of the surgical site.
Choice A rationale: While massage can be soothing, 20 minutes of back massage and effleurage is physically demanding and may not be feasible in an acute care setting. Additionally, positioning a thoracic surgery client for a back massage might cause more incisional discomfort.
Choice B rationale: Guided imagery and slow rhythmic breathing are effective non-pharmacological interventions that reduce the perception of pain by decreasing autonomic nervous system arousal. These techniques empower the client and provide immediate relief without risk of injury to the incision.
Choice C rationale: Applying heat to a fresh surgical site is contraindicated because it increases vasodilation, which can lead to increased edema, bleeding, and potential incision dehiscence. Thermal devices should never be placed directly over a fresh operative site without specific orders.
Choice D rationale: Distraction through television or music can be a helpful adjunct, but it is often less effective than active cognitive-behavioral strategies like guided imagery for a pain level of 5. It serves as a passive intervention rather than an active coping skill.
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