A nurse is caring for a client who had surgery 2 days ago and reports incisional pain. Which of the following actions should the nurse take first?

Determine the time the last dose of pain medication was administered.

Reposition the client to assist with reduction of pain.

Ask the client to describe the pain and rate it on a scale of 0 to 10.

Check the client’s medical record for type of PRN pain medication.

Answer and Explanation

The Correct Answer is C

Choice A Reason

Determine the time the last dose of pain medication was administered. While it is important to know when the last dose of pain medication was given, assessing the client’s current pain level is a priority. This helps in understanding the severity and nature of the pain, which guides further interventions.

Choice B Reason

Reposition the client to assist with reduction of pain. Repositioning can help alleviate pain, but it should be done after assessing the pain. Without understanding the pain’s characteristics, repositioning might not address the underlying issue effectively.

Choice C Reason

Ask the client to describe the pain and rate it on a scale of 0 to 10. This is the correct first action. Pain assessment is crucial in determining the appropriate intervention. By asking the client to describe and rate their pain, the nurse can tailor the pain management plan to the client’s specific needs.

Choice D Reason

Check the client’s medical record for type of PRN pain medication. Reviewing the medical record for PRN pain medication is important, but it should follow the initial pain assessment. Knowing the pain’s intensity and characteristics will help in deciding whether PRN medication is needed.

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Correct Answer is B

Explanation

Choice A Reason

4g sodium diet. While reducing sodium intake is important for managing chronic kidney disease (CKD), a specific 4g sodium diet is not typically prescribed. Instead, patients are generally advised to limit sodium intake to less than 2,300 milligrams per day to help control blood pressure and reduce fluid retention.

Choice B Reason

Potassium-restricted diet. This is the correct intervention. Patients with CKD often have difficulty excreting potassium, leading to hyperkalemia, which can be dangerous. Therefore, a potassium-restricted diet is commonly recommended to maintain normal serum potassium levels.

Choice C Reason

High-phosphorus diet. This statement is incorrect. Patients with CKD are usually advised to limit phosphorus intake because their kidneys cannot effectively excrete phosphorus, leading to hyperphosphatemia. High phosphorus levels can cause bone and cardiovascular problems.

Choice D Reason

High-protein diet. This statement is incorrect. While protein is essential, excessive protein intake can increase the workload on the kidneys. Patients with CKD are often advised to follow a moderate protein diet to reduce the production of waste products that the kidneys need to filter.

A. Notify the provider if you experience a stinging sensation following administration. B. Watch for a decreased heart rate while using this medication. C. You can expect to develop a harmless darkening of the iris. D. This medication can cause the lashes of the affected eye to lengthen.

Correct Answer is B

Explanation

Choice A Reason:

Notifying the provider if you experience a stinging sensation following administration is not necessary. A mild stinging sensation is a common side effect of timolol eye drops and usually subsides quickly. However, if the stinging persists or is severe, it should be reported.

Choice B Reason:

Watching for a decreased heart rate while using this medication is important. Timolol is a beta-blocker, and one of its systemic side effects can be bradycardia (a slower than normal heart rate). Patients should be aware of this potential side effect and monitor their heart rate regularly.

Choice C Reason:

Developing a harmless darkening of the iris is not associated with timolol. This side effect is more commonly linked to prostaglandin analogs, another class of medications used to treat glaucoma.

Choice D Reason:

Timolol does not cause the lashes of the affected eye to lengthen. This side effect is also associated with prostaglandin analogs, not beta-blockers like timolol.

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A nurse is caring for a client who had surgery 2 days ago and reports incisional pain. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has chronic kidney disease. Which of the following diets should the nurse anticipate the provider to prescribe?

Correct Answer is B

Explanation

A nurse is teaching a client who has glaucoma and is to start taking timolol. Which of the following information should the nurse include?

Correct Answer is B

Explanation

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