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","B","C","D","E","F"]
Explanation
A. "This medication should start to alleviate the headache within 1 hour.": Triptans typically provide relief within 1 to 2 hours after administration.
B. "You might experience a feeling of pressure in your chest after taking this medication.": Some clients report a sensation of tightness or pressure in the chest, which is a known, generally benign side effect of triptans.
C. "Do not take more than 200 milligrams of this medication within 24 hours.": A second dose can be taken at least 2 hours after the first dose if the headache persists, but the total dose should not exceed 200 mg in 24 hours for most formulations.
D. "You can take a second dose of this medication at least 2 hours after the initial dose if the headache persists.": A second dose can be taken at least 2 hours after the first dose if the headache persists, but the total dose should not exceed 200 mg in 24 hours for most formulations.
E. "You should discontinue this medication if pregnancy is planned or suspected." Triptans are classified as Category C drugs and should be avoided during pregnancy unless the potential benefit outweighs the risk.
F. "This medication can cause you to feel tired.": Feeling tired is a common side effect of triptans.
G. "You might experience a rash on your skin while taking this medication.": A rash is not a common or expected side effect of triptans. Skin reactions are not a primary concern with these medications unless the client has an allergic response.
Correct Answer is B
Explanation
A. "This medication will protect me from sexually transmitted diseases.": Sildenafil does not prevent sexually transmitted diseases.
B. "I will avoid eating fatty foods, while I take this medication.": Fatty foods can delay the absorption and effectiveness of sildenafil.
C. "I should take this medication twice each day.": Sildenafil is typically taken as needed, not twice daily.
D. "I can expect to have constipation while I take this medication.": Constipation is not a known side effect of sildenafil.
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