A nurse has received change-of-shift report about a client who is 24 hr postoperative following an open cholecystectomy and reports pain. Which of the following actions should the nurse plan to take first?

Administer pain medication.

Instruct the client to splint the incision.

Measure the client's vital signs.

Reposition the client.

Answer and Explanation

The Correct Answer is C

A. Administer pain medication:
Pain medication is important but should not be given before assessing the client’s current status.

B. Instruct the client to splint the incision:
This is helpful during coughing or movement but is not the first action before assessing vital signs.

C. Measure the client's vital signs:
Vital signs provide essential information to determine if the pain could be related to complications such as infection or bleeding before choosing an intervention.

D. Reposition the client:
Repositioning may help relieve discomfort, but assessment takes priority.

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Correct Answer is A

Explanation

A. "Have a backup supply of nonprescription medications.":
A supply of nonprescription medications (e.g., analgesics, antacids, first aid supplies) is essential for managing minor health problems when pharmacy access may be limited.

B. "Replace nonperishable food items annually.":
The CDC and FEMA recommend replacing stored food every 6 months to ensure freshness and nutritional value, not annually.

C. "Stock 2 liters of water per person per day.":
The recommendation is 3.8 liters (1 gallon) per person per day, not 2 liters, to account for drinking and hygiene needs.

D. "Gather enough supplies to last for 2 weeks.":
The standard recommendation is to have enough for at least 3 days (72 hours) for most disaster preparedness; extended stocking may be appropriate in remote areas but is not the baseline recommendation.

A. Client 1 B. Client 2 C. Client 4 D. Client 3 E. Client 5 F. Client 6

Correct Answer is ["B","C","D","E"]

Explanation

A. Client 1:
Cefaclor was scheduled for 0800 and given at 0830 - this is a 30-minute delay, which is generally acceptable unless the medication is time-critical (e.g., insulin, antibiotics for sepsis). Since antibiotics should be given on time, but a 30-min delay is within the acceptable window, this does not require an incident report.

B. Client 2:
The client vomited undigested food and medication 30 minutes after administration. This is a medication effectiveness concern that should be documented and reported because the dose may need to be repeated, and the provider must be notified. An incident report is appropriate.

C. Client 4:
Furosemide was prescribed PO but administered IV at 1400. This is a route error, which is a medication administration error requiring an incident report.

D. Client 3:
Warfarin was administered despite an INR of 3.8 (above the hold parameter of >3.5). This is a clear medication error with potential for harm, requiring an incident report.

E. Client 5:
Gentamicin dose was prescribed at 150 mg IM, but 300 mg IM was given - this is a double dose and a serious medication error requiring immediate incident reporting.

F. Client 6:
Atenolol was appropriately held only if apical pulse <60/min; pulse was 62/min, so administration was within parameters - no error here.

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A nurse has received change-of-shift report about a client who is 24 hr postoperative following an open cholecystectomy and reports pain. Which of the following actions should the nurse plan to take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is ["B","C","D","E"]

Explanation

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