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 C

Explanation

Choice A Reason

The client reports relief from pain when lying in the prone position. This statement is incorrect. Clients with a herniated lumbar disc typically find relief from pain when lying on their back with their knees bent or in a fetal position. Lying prone can sometimes exacerbate the pain.

Choice B Reason

The client reports that their low-back pain radiates upward toward one scapula. This statement is incorrect. Pain from a herniated lumbar disc usually radiates downward into the buttocks, legs, and sometimes the feet, not upward toward the scapula.

Choice C Reason

The client reports tingling and a burning sensation in one foot. This is the correct finding. A herniated lumbar disc can compress spinal nerves, leading to symptoms such as tingling, numbness, and a burning sensation in the legs and feet.

Choice D Reason

The client reports decreased pain when the affected leg is raised. This statement is incorrect. Raising the affected leg often increases pain due to the stretching of the sciatic nerve, which can be compressed by the herniated disc.

A. Initiate insulin drip. B. Monitor blood glucose levels. C. Continue regular diet as tolerated. D. Maintain NPO status until pain-free. E. Manage acute pain.

Correct Answer is ["B","E"]

Explanation

Choice A Reason

Initiate insulin drip. This intervention is not typically included in the standard care plan for all patients with acute pancreatitis. Insulin drips are generally reserved for cases of hypertriglyceridemia-induced pancreatitis, where insulin helps to lower triglyceride levels. For most patients with acute pancreatitis, this is not a standard intervention.

Choice B Reason

Monitor blood glucose levels. This is a correct intervention. Acute pancreatitis can affect the pancreas’ ability to regulate blood sugar, leading to hyperglycemia or hypoglycemia. Monitoring blood glucose levels helps in managing these potential complications and ensuring appropriate treatment.

Choice C Reason

Continue regular diet as tolerated. This statement is incorrect. Patients with acute pancreatitis are usually kept NPO (nothing by mouth) initially to rest the pancreas. Once the inflammation subsides, they may gradually reintroduce oral intake starting with clear liquids and progressing to a low-fat diet.

Choice D Reason

Maintain NPO status until pain-free. This is partially correct but not entirely accurate. While initial management often includes NPO status to rest the pancreas, current guidelines suggest that early enteral feeding can be beneficial and should be started as soon as tolerated. Prolonged NPO status is no longer the standard of care.

Choice E Reason

Manage acute pain. This is a correct intervention. Pain management is a critical component of care for patients with acute pancreatitis. Effective pain control improves patient comfort and can help reduce the stress response associated with severe pain.

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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 assessing a client who has a herniated lumbar disc. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is planning care for a client who has acute pancreatitis. Which of the following interventions should the nurse include in the client’s plan? (Select all that apply.)

Correct Answer is ["B","E"]

Explanation

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