A nurse is caring for a client who is postoperative. When the nurse prepares to change the client's dressing, they say, "Every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action?

Encourage the client to relax and take deep breaths during the dressing change.

Educate the client about the importance of the dressing change to prevent infection.

Assist the client to a comfortable position for the dressing change.

Administer pain medication 45 min before changing the client's dressing.

Answer and Explanation

The Correct Answer is D

A. Encourage the client to relax and take deep breaths during the dressing change: While relaxation and deep breathing can help reduce anxiety and provide some comfort, they do not address the root cause of the client’s pain. Non-pharmacologic measures alone are insufficient when a procedure is known to cause significant procedural pain, making this supportive but not priority.

B. Educate the client about the importance of the dressing change to prevent infection: Patient education is important for adherence and understanding the purpose of care. However, explaining the procedure does not relieve the client’s current pain, and the client may not be able to tolerate the dressing change without adequate analgesia.

C. Assist the client to a comfortable position for the dressing change: Positioning can help reduce discomfort and facilitate access to the surgical site, but it does not eliminate procedural pain. Although this action is supportive and appropriate, it is not the most effective way to prevent or control pain during the dressing change.

D. Administer pain medication 45 min before changing the client's dressing: Administering analgesia prior to a painful procedure is the priority action according to the principles of pain management. Timing the medication to ensure peak effect during the dressing change minimizes procedural pain, improves patient cooperation, and supports overall recovery.

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Correct Answer is C

Explanation

A. "I had a bowel movement, but I was able to save the urine.": This statement indicates a misunderstanding. Urine that is contaminated with fecal matter cannot be included in a 24-hour collection because it may alter the chemical and microscopic analysis. Proper technique requires discarding any urine contaminated with stool and resuming collection with the next void.

B. "I have a specimen in the bathroom from about 30 minutes ago.": Simply having a recent urine sample does not demonstrate understanding of the 24-hour collection process. The client must collect all urine over the entire 24-hour period, starting after the first void is discarded, to ensure accurate measurement of substances such as protein, creatinine, or hormones.

C. "I flushed what I urinated at 7:00 a.m. and have saved all urine since.": This statement demonstrates correct understanding of the procedure. The first morning void is discarded to mark the start of the 24-hour collection, and all subsequent urine is collected in the designated container. This ensures that the total volume represents a full 24-hour period for accurate analysis.

D. "I drink a lot, so I will fill up the bottle and complete the test quickly.": Rapidly filling the collection container by excessive fluid intake does not adhere to the 24-hour collection protocol. The collection must include all urine voided naturally over the 24-hourperiodregardless of fluid intake, to maintain accuracy in measuring the substances of interest.

A. Have the client wear a mask when receiving visitors. B. Wear a gown when caring for the client. C. Assign the client to a room with negative-pressure airflow exchange. D. Limit the client's time with visitors to no more than 30 min per day.

Correct Answer is B

Explanation

A. Have the client wear a mask when receiving visitors: Mask use is primarily indicated for airborne or droplet precautions to prevent respiratory transmission of pathogens. Shigella is transmitted via the fecal-oral route, not through respiratory droplets, so a mask is not required for visitors or staff in this case.

B. Wear a gown when caring for the client: Contact precautions are appropriate for clients with diarrhea caused by Shigella because the bacteria can be transmitted through direct or indirect contact with fecal matter. Wearing a gown protects the nurse’s clothing from contamination and helps prevent the spread of infection to other clients or surfaces.

C. Assign the client to a room with negative-pressure airflow exchange: Negative-pressure rooms are used for airborne pathogens such as tuberculosis, not for enteric infections like Shigella. Shigella does not remain suspended in the air and therefore does not require special airflow control.

D. Limit the client's time with visitors to no more than 30 min per day: Restricting visitation time is not a standard precaution for fecal-oral infections. Infection control relies on proper hand hygiene, use of personal protective equipment, and environmental cleaning rather than strictly limiting visitor duration.

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A nurse is caring for a client who is postoperative. When the nurse prepares to change the client's dressing, they say, "Every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action?

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