A nurse is assessing a client for acute postoperative pain. Which of the following actions should the nurse take first?

Provide an analgesic for pain.

Obtain a self-report from the client.

Observe the client's behaviors.

Develop a behavioral pain score.

Answer and Explanation

The Correct Answer is B

A. Provide an analgesic for pain. Administering medication is important but should be done after assessing the pain.
B. Obtain a self-report from the client. The client's self-report is the most reliable indicator of pain and should be obtained first.
C. Observe the client's behaviors. Observing behaviors is helpful but should follow the self-report to validate the client's experience.
D. Develop a behavioral pain score. This can be useful for non-verbal clients, but the self-report is the primary method of assessment for verbal clients.

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Correct Answer is D

Explanation

A. Instruct the client to take a sitz bath three times a week. While sitz baths may provide symptom relief, they are not a primary intervention for treating a UTI.
B. Request a prescription for gabapentin. Gabapentin is used for neuropathic pain, not for treating UTIs.
C. Encourage the client to drink 2 oz of grapefruit juice each day. Grapefruit juice is not recommended for UTIs; cranberry juice is often suggested instead.
D. Increase the client's fluid intake to 3 L each day. Increasing fluid intake helps flush bacteria from the urinary tract and is a key intervention in managing UTIs.

A. Provide information about the risks of a surgical procedure to the client. B. Request the client sign the informed consent form after administering a preoperative sedative. C. Mark the client's surgical site with a small strip of nonporous tape. D. Call a "time out" to verify client identity before starting a surgical procedure.

Correct Answer is D

Explanation

A. Provide information about the risks of a surgical procedure to the client. Providing risk information is part of informed consent, not specifically part of Universal Protocol.
B. Request the client sign the informed consent form after administering a preoperative sedative. Informed consent should be obtained before administering sedatives to ensure the client is fully aware and able to consent.
C. Mark the client's surgical site with a small strip of nonporous tape. The surgical site should be marked with a permanent marker to ensure it remains visible and clear throughout the surgical preparation and procedure.
D. Call a "time out" to verify client identity before starting a surgical procedure. This is correct. The Universal Protocol includes a "time out" to verify the correct patient, procedure, and site before starting the surgery.

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A nurse is assessing a client for acute postoperative pain. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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