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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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A Reason

“Lie on your left side.” This statement is incorrect. After a liver biopsy, the client should lie on their right side to apply pressure to the biopsy site and help prevent bleeding.

Choice B Reason

“Lie on your right side.” This is the correct instruction. Lying on the right side helps compress the liver biopsy site, reducing the risk of bleeding and promoting clot formation.

Choice C Reason

“Increase your fluid intake.” This statement is not specifically related to post-liver biopsy care. While staying hydrated is generally good advice, it is not a primary instruction for post-biopsy care.

Choice D Reason

“Decrease your fluid intake.” This statement is incorrect. There is no need to decrease fluid intake after a liver biopsy. Proper hydration is important for overall health and recovery.

A. Increase hydration. B. Monitor blood pressure. C. Measure urine output. D. Provide a calm environment.

Correct Answer is B

Explanation

Choice A Reason:

Increasing hydration is important in the postoperative period to maintain fluid balance and support recovery. However, it is not the immediate priority following pheochromocytoma removal. The primary concern is to monitor and manage hemodynamic stability, particularly blood pressure.

Choice B Reason:

Monitoring blood pressure is the priority action following pheochromocytoma removal. This surgery can lead to significant fluctuations in blood pressure due to the sudden removal of catecholamine-secreting tumors. Close monitoring is essential to detect and manage potential hypotension or hypertension, which can be life-threatening if not promptly addressed.

Choice C Reason:

Measuring urine output is important for assessing kidney function and fluid balance, but it is not the immediate priority. Blood pressure monitoring takes precedence because of the potential for severe hemodynamic instability following the removal of the tumor.

Choice D Reason:

Providing a calm environment is beneficial for the patient’s overall recovery and can help reduce stress and anxiety. However, it is not the most critical action immediately following surgery. Ensuring hemodynamic stability through blood pressure monitoring is the top priority.

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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 is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?

Correct Answer is B

Explanation

A nurse is caring for a client who is postoperative immediately following a pheochromocytoma removal. Which of the following actions is the nurse’s priority?

Correct Answer is B

Explanation

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