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: While bowel incontinence is a concern, it does not pose an immediate threat to the client's physiological stability like fluid volume deficit does.

Choice B reason: Impaired bed mobility is important to address for long-term rehabilitation, but it is not the most immediate threat to life.

Choice C reason: Fluid volume deficit, especially due to diarrhea, can lead to dehydration and is a life-threatening condition that requires immediate intervention.

Choice D reason: Caregiver role strain is a significant issue but does not take precedence over the client's immediate physical health needs.

A. Skin turgor. B. Weight. C. Blood pressure. D. Lung sounds.

Correct Answer is B

Explanation

Choice A reason: Skin turgor is a method to assess hydration status, but it is not the most accurate indicator of fluid balance in a patient with fluid volume overload.

Choice B reason: Monitoring weight is the most accurate method to assess fluid balance. A sudden increase or decrease in weight is indicative of fluid changes.

Choice C reason: Blood pressure can be affected by fluid volume changes, but it does not provide a direct measure of fluid balance.

Choice D reason: Lung sounds can indicate fluid overload in the lungs but do not give a complete picture of overall fluid balance.

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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

The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home, and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?

Correct Answer is C

Explanation

A patient with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the patient's fluid balance?

Correct Answer is B

Explanation

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