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 D

Explanation

A) Protamine:
Protamine is used to reverse the anticoagulant effects of heparin, not warfarin. It is not effective in reversing warfarin overdose.

B) Epinephrine:
Epinephrine is a medication used to treat severe allergic reactions (anaphylaxis) and cardiac arrest. It is not indicated for reversing warfarin overdose.

C) Atropine:
Atropine is used to treat bradycardia and certain types of poisoning but has no role in reversing the effects of warfarin overdose.

D) Vitamin K:
Vitamin K is the antidote for warfarin overdose. Warfarin inhibits vitamin K-dependent clotting factors, and administering vitamin K helps replenish these factors, thereby reversing the anticoagulant effects of warfarin.

A. Shave excess hair from skin before applying a nitroglycerin patch. B. Keep a nitroglycerin patch in place 24 hr. per day. C. Put a second patch in place if angina pain occurs. D. Fold used patch with medication area to the inside and discard in a closed receptacle.

Correct Answer is D

Explanation

A) Shave excess hair from skin before applying a nitroglycerin patch:
Shaving excess hair is not necessary for applying a nitroglycerin patch. The patch should be applied to a clean, dry, and hairless area of skin to ensure proper adhesion and absorption of medication.

B) Keep a nitroglycerin patch in place 24 hr. per day:
Nitroglycerin patches are typically worn for a specified period (usually 12 to 14 hours) and then removed for a "patch-free" interval to prevent tolerance development. Continuous use can lead to tolerance, reducing the effectiveness of the medication.

C) Put a second patch in place if angina pain occurs:
Applying a second nitroglycerin patch is not recommended without consulting a healthcare provider. Increasing the dosage of nitroglycerin without proper medical advice can lead to hypotension and other adverse effects. The client should follow the prescribed regimen and seek medical assistance if angina pain is not relieved.

D) Fold used patch with medication area to the inside and discard in a closed receptacle:
This is the correct instruction. Used nitroglycerin patches should be folded with the adhesive side together (medication area inside) to prevent accidental exposure and disposed of in a closed receptacle. This helps ensure safe disposal and prevents unintentional contact with the medication by others.

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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

A nurse is caring for a client who is receiving warfarin therapy to prevent a deep vein thrombosis. Which of the following medications should the nurse have available in the event of an overdose?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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