A nurse is caring for a client with cholecystitis who is experiencing severe abdominal pain. Which of the following actions should the nurse take first?
Administer pain medication as prescribed.
Assess the client's vital signs and pain level.
Place the client in a semi-Fowler's position.
Offer the client a cup of herbal tea for relaxation.
The Correct Answer is B
Choice A reason:
Administering pain medication is important, but assessing the client's vital signs and pain level takes priority to determine the severity of the pain and the appropriate intervention.
Choice B reason:
This statement is correct. Assessing the client's vital signs and pain level is the first action the nurse should take to evaluate the client's condition and determine the appropriate intervention.
Choice C reason:
Placing the client in a semi-Fowler's position may provide some comfort, but it does not address the underlying pain or assist in determining the severity of the situation.
Choice D reason:
Offering herbal tea for relaxation is a non-pharmacological intervention that can be helpful, but it is not the first action the nurse should take when the client is experiencing severe abdominal pain.
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Related Questions
Correct Answer is D
Explanation
Choice A reason:
Encouraging the client to eat a high-fat meal the night before the surgery is not recommended. Instead, clients scheduled for surgery, especially abdominal surgery, are typically instructed to have a clear liquid diet or nothing by mouth (NPO) after midnight to prevent aspiration during anesthesia.
Choice B reason:
Administering antibiotics prophylactically before surgery is often done to prevent infection during the procedure. However, it is at the discretion of the healthcare provider based on the client's specific condition and surgical plan.
Choice C reason:
Avoiding deep breathing exercises is not recommended preoperatively. Deep breathing exercises help prevent respiratory complications after surgery and promote lung function.
Choice D reason:
This statement is correct. Instructing the client to remain NPO after midnight before the surgery is essential to prevent aspiration during anesthesia. Clients should not eat or drink anything after the specified time to ensure their stomach is empty during the surgery.
Correct Answer is C
Explanation
Choice A reason:
Deep breathing exercises do not directly prevent postoperative infection. However, they can help with postoperative lung expansion and prevent respiratory complications, indirectly reducing the risk of infection.
Choice B reason:
While deep breathing exercises can help improve respiratory function, they are not specifically targeted at strengthening abdominal muscles.
Choice C reason:
This statement is correct. Deep breathing exercises promote lung expansion and prevent atelectasis (partial lung collapse) after surgery. They help maintain adequate oxygenation and prevent respiratory complications.
Choice D reason:
Deep breathing exercises are not directly related to reducing the risk of gallstone formation. Gallstone formation is primarily influenced by factors such as diet, bile composition, and gallbladder function.
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