A nurse is caring for a one-day postoperative client. Which of the following would be the priority for the nurse?
Client blood pressure 118/70
Client reports pain severity 6/10
Client appears anxious when family arrives
Client requests information about pain medications
The Correct Answer is B
Choice A reason: Blood pressure 118/70 is normal, indicating stable hemodynamics. Pain (6/10) is more urgent, as uncontrolled pain increases stress hormones, impairing healing and risking complications like atelectasis, making blood pressure a lower priority in this postoperative scenario.
Choice B reason: Pain severity of 6/10 is a priority, as moderate postoperative pain increases catecholamine release, impairing healing and raising risks of complications like atelectasis or hypertension. Prompt pain management improves recovery, preventing physiological stress, making this the most urgent issue to address.
Choice C reason: Anxiety when family arrives is psychosocial but less urgent than pain (6/10). Pain causes physiological stress, increasing risks like impaired healing or respiratory complications, while anxiety’s impact is less immediate, making it secondary to effective pain management.
Choice D reason: Requesting pain medication information indicates a need for education but is less urgent than addressing pain (6/10). Uncontrolled pain risks physiological complications like increased heart rate or poor healing, making pain management the priority over providing medication information.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A Jackson-Pratt drain removes serous fluid and blood from the surgical site, preventing seromas, hematomas, or infections. By maintaining a closed suction system, it promotes wound healing and reduces complications, making this the primary purpose of the JP drain in postoperative care.
Choice B reason: While a JP drain may remove small amounts of blood, its primary purpose is preventing fluid accumulation, not limiting bleeding. Bleeding control is managed intraoperatively or with other measures, making this a secondary, less accurate purpose of the drain compared to fluid prevention.
Choice C reason: A JP drain is not used for medication administration. It is a closed suction system designed to remove fluid from the surgical site to prevent complications. Medications are given via other routes (e.g., IV), making this an incorrect description of the drain’s purpose.
Choice D reason: A JP drain does not eliminate the need for wound irrigations, which clean wounds directly. The drain prevents fluid buildup in closed surgical sites, reducing infection risk, but it does not replace irrigation, which addresses different wound care needs, making this choice incorrect.
Correct Answer is []
No explanation
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