A nurse is caring for a client who is 24 hours postoperative following abdominal surgery. The client received an opioid analgesic 1 hour ago and now reports a pain level of 2 on a scale of 0 to 10. Which of the following actions should the nurse take?

Administer an additional dose of pain medication.

Maintain the client on bed rest.

Apply a warm, moist compress to the incision area.

Reposition the client.

Answer and Explanation

The Correct Answer is D

Choice A reason: An additional dose of pain medication is not necessary as the client reports a low pain level of 2, indicating effective pain control.

Choice B reason: Maintaining the client on bed rest is not required unless specified by the postoperative care plan. It is generally beneficial to mobilize the client as soon as possible to prevent complications.

Choice C reason: A warm, moist compress may be applied to the incision area if there is specific discomfort or as per the care plan, but it is not indicated solely based on the pain level reported.

Choice D reason: Repositioning the client can help alleviate discomfort and prevent pressure ulcers. It is a suitable action given the low pain level reported.

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Correct Answer is D

Explanation

Choice A reason:Aspiration pneumonia is typically caused by inhalation of foreign material into the lungs rather than by contagious pathogens. Therefore, standard precautions are usually sufficient unless a secondary infection with a transmissible organism is present.

Choice B reason: Applying petroleum jelly to the client's nares may provide comfort but is not a priority in the care plan.

Choice C reason: Maintaining the client in a supine position is contraindicated as it can increase the risk of aspiration.

Choice D reason: Clients with hypoxia may experience symptoms such as confusion, restlessness, and dizziness, which can increase the risk of falls. Implementing fall precautions is a proactive measure to ensure patient safety in this context.

A. Rest in a soft chair. B. Use a continuous passive motion machine. C. Apply moist heat prior to ambulation. D. Delay ambulation until the next day.

Correct Answer is C

Explanation

Choice A reason: Resting in a soft chair may provide comfort but does not actively address the stiffness experienced upon ambulation.

Choice B reason: A continuous passive motion machine is typically used postoperatively for knee surgeries, not for routine management of osteoarthritis stiffness.

Choice C reason: Applying moist heat helps to relax muscles and increase circulation, which can reduce stiffness and make ambulation easier.

Choice D reason: Delaying ambulation may lead to further stiffness and is not recommended as regular movement is beneficial for joint health.

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A nurse is caring for a client who is 24 hours postoperative following abdominal surgery. The client received an opioid analgesic 1 hour ago and now reports a pain level of 2 on a scale of 0 to 10. Which of the following actions should the nurse take?

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