A nurse is caring for a client who is 1-day postoperative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first?
Ask the client to rate her pain on a scale from 0 to 10.
Reposition the client and offer her a back rub.
Determine the time the client last received pain medication.
Measure the client's vital signs, including temperature.
The Correct Answer is A
A) Ask the client to rate her pain on a scale from 0 to 10:
Assessing the client's pain intensity is the first essential step in managing postoperative pain. Understanding the severity of pain will guide the nurse in determining the appropriate intervention and whether immediate pain relief measures or further assessment are needed.
B) Reposition the client and offer her a back rub:
Repositioning and providing comfort measures like a back rub can help alleviate discomfort, but assessing the pain level first is crucial to prioritize interventions effectively.
C) Determine the time the client last received pain medication:
Knowing the timing of the last pain medication dose is important but assessing current pain intensity takes precedence to determine if the client needs immediate pain relief.
D) Measure the client's vital signs, including temperature:
While vital signs are important for overall assessment, addressing pain management and comfort should be the initial focus after the client reports incisional pain postoperatively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Trazolam orally at bedtime:
Trazolam is a benzodiazepine used for insomnia and can cause daytime sedation. Clients should avoid hazardous activities, such as driving, while taking this medication due to the potential for impaired alertness and coordination.
B) Polyethylene glycol dissolved in 240 ml of water once daily:
Polyethylene glycol is a laxative used for bowel cleansing and maintenance. It does not typically cause daytime sedation or impair cognitive function, so avoiding hazardous activities is not necessary.
C) Adalimumab subcutaneously every 2 weeks:
Adalimumab is a biologic medication used to treat inflammatory conditions like rheumatoid arthritis and does not typically cause sedation or impair cognitive function.
D) Ketoconazole orally once daily with food:
Ketoconazole is an antifungal medication that does not cause significant sedation or impair cognitive function. Hazardous activities are not typically restricted while taking this medication.
Correct Answer is C
Explanation
A) Vomiting:
Vomiting can occur postoperatively due to various reasons such as anesthesia, medications, or surgical stress. While vomiting should be monitored closely for dehydration and electrolyte imbalance, it is not typically an early sign of circulatory overload.
B) Flushing:
Flushing, or skin redness and warmth, can occur due to vasodilation from anesthesia or medications. It is not specific to circulatory overload unless accompanied by other signs such as dyspnea, elevated blood pressure, and fluid retention.
C) Dyspnea:
Dyspnea, or difficulty breathing, is a critical early sign of circulatory overload in clients receiving IV fluids and blood products. It indicates fluid accumulation in the lungs, necessitating immediate nursing intervention to prevent respiratory distress.
D) Bradycardia:
Bradycardia, or a slow heart rate, can occur postoperatively due to anesthesia effects or vagal stimulation. However, it is not typically associated with circulatory overload, which more commonly manifests with tachycardia as the heart attempts to compensate for increased fluid volume.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.