A nurse is caring for a client who had abdominal surgery. The client is grimacing and has a respiratory rate of 24/min. Which of the following actions should the nurse take first?
Offer the client a cold compress.
Play music in the client's room as a distraction.
Check the client's current level of pain.
Assist the client to reposition in bed.
The Correct Answer is C
A. Offer the client a cold compress: While a cold compress might help with swelling or discomfort, it is more important to assess the client's pain level first to understand the cause of the grimacing.
B. Play music in the client's room as a distraction: This could help later, but pain needs to be addressed first.
C. Check the client's current level of pain: Grimacing could indicate pain, which should be evaluated and addressed first to provide comfort and prevent complications like increased stress or decreased respiratory effort.
D. Assist the client to reposition in bed: Repositioning could help alleviate discomfort, but pain should be assessed first to ensure the client is not in severe pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Increased respiratory rate: Naloxone reverses respiratory depression caused by opioids, so an improvement in respiratory rate indicates effectiveness.
B. Report of decreased pain: Naloxone reverses opioid effects, including pain relief. Pain might increase, not decrease, following naloxone administration.
C. Increased temperature: Naloxone does not directly affect body temperature.
D. Decreased blood pressure: Naloxone is not associated with a direct effect on blood pressure; instead, it reverses opioid-induced hypotension.
Correct Answer is D
Explanation
A. 15 g of carbohydrates: This is used for hypoglycemia, not for hypotension.
B. Naloxone: Naloxone is an opioid antagonist, not relevant for ramipril-related symptoms.
C. Diphenhydramine: This is an antihistamine and not indicated for ramipril-related dizziness.
D. Fluid bolus: Dizziness and lightheadedness after starting an ACE inhibitor like ramipril may be due to hypotension. A fluid bolus can help restore blood volume and alleviate these symptoms.
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