A nurse is caring for a client who is 24 hr postoperative following abdominal surgery. The client received an opioid analgesic 1 hr 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?
Maintain the client on bed rest.
Apply a warm, moist compress to the incision area.
Administer an additional dose of pain medication.
Reposition the client.
The Correct Answer is D
Answer is: d. Reposition the client.
Explanation: Repositioning the client can help alleviate pain by redistributing pressure and promoting comfort. Since the client's pain level is relatively low (2 on a scale of 0 to 10), this non-pharmacological intervention is an appropriate initial action.
Choice a. is wrong because maintaining the client on bed rest is not an appropriate action for a pain level of 2. Instead, the nurse should encourage the client to mobilize and perform appropriate exercises to prevent complications related to immobility.
Choice b. is wrong because applying a warm, moist compress to the incision area might not be the best action for a client who is 24 hours postoperative, as it could increase the risk of infection and cause discomfort. Cold compresses are often used in the initial postoperative period to reduce swelling and promote comfort.
Choice c. is wrong because administering an additional dose of pain medication is not necessary at this point, as the client's pain level is relatively low. The nurse should consider non-pharmacological interventions first and reassess the client's pain level to determine the need for further pain relief.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C, weigh the client before and after the treatment. The nurse should weigh the client before and after the treatment to evaluate the effectiveness of the dialysis, and determine whether the appropriate amount of fluid has been removed. Choice A is incorrect because the dialysate should be warmed prior to infusion, not chilled. Choice B is incorrect because sterile gloves, not clean gloves, are required when handling dialysate bags. Choice D is incorrect because diarrhea is not a common complication of peritoneal dialysis.
Choice A: Chilling the dialysate prior to infusion is incorrect because the dialysate should be warmed prior to infusion, not chilled.
Choice B: Using clean gloves when handling dialysate bags is incorrect because sterile gloves, not clean gloves, are required when handling dialysate bags.
Choice D: Monitoring the client for diarrhea is incorrect because diarrhea is not a common complication of peritoneal dialysis.
Correct Answer is C
Explanation
A bladder infection can lead to confusion or other changes in mental status, especially in older adults. A normal temperature and WBC count do not necessarily indicate a bladder infection. Diminished reflexes are not typically associated with a bladder infection.
A: A temperature of 37.3° C (99.1° F) is within the normal range and does not necessarily indicate a bladder infection.
B: A WBC count of 9,000/mm3 is within the normal range and does not necessarily indicate a bladder infection.
D: Diminished reflexes are not typically associated with a bladder infection.
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