A nurse is caring for a client who is postoperative. When helping to manage the client's pain, which of the following principles should the nurse apply? (Select all that apply.).

Use a scale from 0 to 10 to monitor the severity of the client's pain.

Consider the client's individual expression of pain.

Expect the client to express his pain both verbally and nonverbally.

Administer opioids with caution because they will eventually lead to addiction.

To achieve fast-acting pain relief, administer analgesics.

Answer and Explanation

Correct Answer : A,B,E

Choice A rationale:
Using a pain scale from 0 to 10 is a crucial principle in managing a client's postoperative pain. It allows for a standardized assessment of pain severity and helps healthcare providers determine the effectiveness of pain management interventions.
Choice B rationale:
Considering the client's individual expression of pain is essential in providing personalized care. People experience and express pain differently, so tailoring the approach to each client's unique needs is vital for effective pain management.
Choice C rationale:
Expecting the client to express pain both verbally and nonverbally is another important principle in pain management. Some clients may not be able to communicate verbally, so nurses should be attentive to nonverbal cues such as grimacing, restlessness, or changes in vital signs to assess pain.
Choice D rationale:
Administering opioids with caution is a general principle in pain management, but the statement that they will eventually lead to addiction is an oversimplification. While there is a risk of opioid addiction, it is not an absolute certainty, and the benefits of pain relief often outweigh the risks. Therefore, this statement is not entirely accurate.
Choice E rationale:
Administering analgesics for fast-acting pain relief is a valid principle, especially in the postoperative period when the client may be experiencing acute pain. Fast-acting analgesics help alleviate immediate discomfort.

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Correct Answer is D

Explanation

Choice A rationale:

Using heavy pressure on the cold pack for greater effectiveness is not the correct approach when applying a cold pack to an injured area. Applying excessive pressure can lead to tissue damage, frostbite, and can be uncomfortable for the patient. Cold packs should be applied with gentle, even pressure to avoid complications.

Choice B rationale:

Leaving the cold pack in place for over 30 minutes at a time is not recommended. Prolonged exposure to cold can also cause tissue damage, including frostbite. It is generally advised to limit cold pack applications to 20-30 minutes at a time to prevent complications.

Choice C rationale:

Preparing to apply heat instead if cold is not effective is not the appropriate action in this scenario. When a healthcare provider orders a cold pack application, it is essential to follow the prescribed treatment plan. Heat should only be considered if it is specifically ordered as an alternative treatment.

Choice D rationale:

Placing a towel between the pack and the skin is the correct approach to prevent patient injury when applying a cold pack. This helps to protect the skin from direct contact with the cold pack, reducing the risk of frostbite or cold-related injuries. It ensures a barrier between the cold pack and the patient's skin, providing a safe and comfortable application.

A. "Your husband should decide when more medication is needed.”. B. "Why do you think your husband needs more medication when he is asleep?". C. "It's a good idea to help make sure your husband can sleep comfortably.”. D. "Next time you think he needs more medication, call me and I'll push the button.”.

Correct Answer is B

Explanation

The correct answer is choice B. "Why do you think your husband needs more medication when he is asleep?"

Choice A rationale:

"Your husband should decide when more medication is needed.” This response is incorrect because it implies that the partner has the authority to decide when the client needs pain medication, which violates the purpose of a PCA pump. A PCA pump is specifically designed for client-controlled pain management, ensuring that the patient, not anyone else, controls when they receive pain medication. Allowing someone else to press the button can lead to overmedication and safety risks.

Choice B rationale:

"Why do you think your husband needs more medication when he is asleep?" This response is correct because it prompts the partner to reflect on their actions and provides an opportunity for the nurse to educate about the proper use of PCA pumps. It addresses the immediate issue without being confrontational and opens the door for further discussion on the importance of client safety and correct PCA use.

Choice C rationale:

"It's a good idea to help make sure your husband can sleep comfortably.” This response is incorrect as it endorses inappropriate and unsafe behavior. It encourages the partner to continue pressing the PCA button, risking the client's safety due to potential overmedication, which can lead to severe complications, such as respiratory depression.

Choice D rationale:

"Next time you think he needs more medication, call me and I'll push the button.” This response is incorrect because it contradicts PCA protocols and removes the control from the client. The nurse is responsible for monitoring the client’s pain and safety, not administering medication upon another person’s request. This approach also increases the risk of dosing errors and undermines the purpose of patient-controlled analgesia.

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A nurse is caring for a client who is postoperative. When helping to manage the client's pain, which of the following principles should the nurse apply? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for a patient who suffered a severe sprain and has an order for a cold pack application to the injured area would prevent patient injury by:.

Correct Answer is D

Explanation

A nurse is caring for a client who is using a patient-controlled analgesia (PCA) pump for postoperative pain management. The nurse enters the room to find the client asleep and his partner pressing the button to dispense a dose of analgesia. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

Choice A rationale:

Choice B rationale:

Choice C rationale:

Choice D rationale:

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