A nurse is caring for a client who is 1 day postoperative following surgery and reports incisional pain. Which of the following actions should the nurse take first?
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.
Ask the client to rate her pain on a scale from 0 to 10.
The Correct Answer is D
A. Reposition the client and offer her a back rub:
Non-pharmacologic interventions are helpful, but only after assessing the pain level.
B. Determine the time the client last received pain medication:
This is done after establishing the pain score to decide on safe administration of further analgesia.
C. Measure the client's vital signs, including temperature:
Vital signs may help assess systemic complications, but they do not measure pain directly.
D. Ask the client to rate her pain on a scale from 0 to 10:
The first step in pain management is to assess the intensity, location, and nature of the pain using a pain scale.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Peripheral edema:
Edema is a sign of fluid overload, not fluid loss or hypovolemia.
B. Capillary refill that returns immediately:
In hypovolemia, capillary refill is typically delayed (>2 seconds) due to poor perfusion.
C. Hypertension:
Hypovolemia often causes hypotension due to reduced circulating volume.
D. Oliguria:
Decreased urine output (<30 mL/hr) is a classic sign of hypovolemia, as the kidneys reduce output to conserve fluid.
Correct Answer is C
Explanation
A. Dementia:
Dementia is a chronic, progressive cognitive decline, not an acute condition. It does not cause sudden, temporary disorientation post-surgery.
B. Alzheimer's disease:
Alzheimer's is a form of dementia and also a chronic, irreversible condition, not associated with acute postoperative confusion.
C. Postoperative delirium:
This is an acute, fluctuating mental status change that occurs shortly after surgery, especially in older adults. It's typically reversible and may include disorientation, agitation, or confusion.
D. Postoperative cognitive dysfunction (POCD):
POCD is usually more subtle and long-lasting, affecting memory and concentration weeks to months post-op, not an immediate disorientation after surgery.
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