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.
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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Related Questions
Correct Answer is B
Explanation
A. Ask the provider to give consent for the transfusion:
Providers cannot override a legally authorized healthcare proxy when the client lacks decision-making capacity.
B. Respect the daughter's decision to refuse the transfusion:
A durable power of attorney for health care grants the designated individual legal authority to make decisions when the client is unable to do so, even if it means refusing treatment.
C. Encourage the daughter to let her mother have the transfusion:
This may be perceived as coercive and disregards the daughter’s legal decision-making authority.
D. Discuss taking guardianship of the client with the facility administration:
Guardianship is not needed when a valid durable power of attorney for health care is in place.
Correct Answer is C
Explanation
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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