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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A) "Heparin prevents new clots from forming rather than dissolving established clots":
Heparin works primarily by inhibiting the formation of new clots and preventing existing clots from growing larger. It does not actively dissolve established clots. Instead, the body's natural fibrinolytic system is responsible for breaking down existing clots over time.

B) "The time it takes for heparin to dissolve a clot depends on the size of the clot":
While the size of the clot can influence the duration of treatment with heparin, heparin itself does not directly dissolve clots. Factors such as clot location, patient's overall health, and the body's natural fibrinolytic activity contribute to the resolution of the clot over time.

C) "It usually takes at least 2 to 3 days for heparin to dissolve a clot":
This statement is incorrect because heparin does not dissolve clots. It prevents the clot from growing larger and gives the body time to naturally break down the clot through fibrinolysis, which typically takes longer than a few days.

D) "The time it takes heparin to dissolve clots varies between clients":
This statement is partially correct, as the time it takes for a clot to resolve can vary based on individual factors such as clot size, location, and the body's natural fibrinolytic process. However, heparin itself does not directly dissolve clots.

A. Cimetidine 300 mg PO four times per day B. Furosemide 80 mg PO daily C. Acyclovir 400 mg PO twice daily D. Meloxicam 5 mg PO once daily

Correct Answer is B

Explanation

A) Cimetidine 300 mg PO four times per day:
Cimetidine, a histamine-2 (H2) receptor antagonist used to treat gastric acid-related disorders, does not typically affect potassium levels. Its mechanism of action involves reducing stomach acid production rather than impacting electrolyte balance.

B) Furosemide 80 mg PO daily:
Furosemide is a loop diuretic that inhibits sodium and chloride reabsorption in the loop of Henle, leading to increased urinary excretion of potassium (potassium wasting). This mechanism can result in hypokalemia, especially with higher doses or prolonged use.

C) Acyclovir 400 mg PO twice daily:
Acyclovir is an antiviral medication primarily used for herpes simplex virus infections. It does not have a known association with causing hypokalemia.

D) Meloxicam 5 mg PO once daily:
Meloxicam is a nonsteroidal anti-inflammatory drug (NSAID) used for pain relief and inflammation. It does not affect potassium levels and is not associated with causing hypokalemia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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