A nurse is applying a cold compress for pain and minor swelling for a client who has a sutured laceration on the forearm. Which of the following data-collection activities should the nurse use to determine whether the treatment is effective?
Having the client perform range-of-motion exercises of the arm
Inspecting the site for reduced swelling
Asking the client to rate the pain
Monitoring the client's pulse rate
The Correct Answer is C
The correct answer is c. Asking the client to rate the pain. This is the most direct and reliable method to determine the effectiveness of a cold compress for pain relief.
Choice A Reason:
Having the client perform range-of-motion exercises of the arm: This statement is incorrect because it assesses mobility rather than pain or swelling. Range-of-motion exercises are typically used to evaluate joint flexibility and muscle strength, not the effectiveness of pain relief measures.
Choice B Reason:
Inspecting the site for reduced swelling: This statement is incorrect because, while it checks for swelling, it does not directly measure pain relief. Swelling reduction can be an indicator of decreased inflammation, but it does not provide a direct assessment of the client's pain levels.
Choice C Reason:
Asking the client to rate the pain: This is the correct choice because it directly measures the client's perception of pain. Pain is a subjective experience, and the most accurate way to assess it is by asking the client to describe or rate their pain. This method allows the nurse to gauge the effectiveness of the cold compress in providing pain relief.
Choice D Reason:
Monitoring the client's pulse rate: This statement is incorrect because pulse rate is not a direct indicator of pain or swelling reduction. While pain can sometimes cause an increase in pulse rate, it is not a reliable or specific measure of pain relief. Pulse rate can be influenced by various factors, including stress, anxiety, and physical activity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
Choice A reason: Restlessness can be a sign of discomfort or pain, especially in a postoperative client. It may manifest as constant shifting or an inability to remain still, indicating that the client is trying to find a position that alleviates the pain.
Choice B reason: Clenching, such as tightly gripping the handrails of the bed or making fists, can indicate that the client is trying to manage pain or discomfort through tension in the muscles.
Choice C reason: Grimacing, or making a pained facial expression, is a clear nonverbal cue of pain. It often involves furrowing the brow, closing the eyes tightly, or contorting the mouth.
Choice D reason: Drowsiness is not typically a direct indicator of pain. It may be related to medication effects, fatigue, or the body's response to healing post-surgery. However, it does not specifically signal pain.
Choice E reason: Moaning, groaning, or making other vocal sounds can be a response to pain, particularly in clients who are unable to articulate their pain verbally due to sedation or other factors.
Correct Answer is C
Explanation
Choice A reason: Wrapping the dressing in a clear plastic bag and discarding it in the bedside trash receptacle is not an appropriate method for disposing of soiled dressings. This approach does not comply with standard infection control protocols, as it could potentially expose healthcare workers and others to biohazardous materials.
Choice B reason: Simply discarding the dressing in the bedside trash receptacle is also inappropriate and unsafe. This method does not contain the biohazardous material properly and could lead to contamination and spread of infectious agents.
Choice C reason: Placing the dressing in a biohazardous waste container is the correct method for disposing of dressings saturated with blood and purulent drainage. According to infection control guidelines, materials that are soaked with potentially infectious agents should be disposed of in designated biohazardous waste containers. These containers are typically red or yellow and are labeled to indicate that they contain materials that require special handling.
Choice D reason: Double bagging the dressing, labeling it "biohazard," and sending it for decontamination is an unnecessary step for routine disposal of soiled dressings. While double bagging may be used in situations where there is a significant spill or leak risk, it is not typically required for standard disposal of wound dressings.
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