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.
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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
A. Adjust the suction pressure, assess the client's response, don clean gloves, insert the suction catheter without suction, apply suction while withdrawing the catheter:
Gloves must be sterile, not clean, for trach suctioning. Also, suction must be tested before insertion.
B. Don sterile gloves, adjust suction pressure, apply suction while inserting the suction catheter, withdraw the catheter without suction, assess the client's response:
Suction should never be applied while inserting the catheter-this can damage mucosa and cause hypoxia.
C. Adjust suction pressure, don sterile gloves, test suction, insert the suction catheter without suction, apply suction while withdrawing the catheter, assess the client's response:
This is the proper sequence for safe and effective suctioning.
D. Don sterile gloves, assess the client's response, adjust the suction pressure, insert the suction catheter without suction, apply suction while withdrawing the catheter:
Suction pressure should be adjusted before donning sterile gloves, and suction should be tested before catheter insertion.
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