A nurse is caring for a patient who recently had abdominal surgery and is experiencing severe pain. The patient’s blood pressure is 110/60 mmHg, and heart rate is 60 beats/min. Additionally, the patient does not appear to be in any distress. Which response by the nurse is most therapeutic?

I will go get you some narcotic pain relievers immediately.

Your vitals do not show that you are having pain; can you describe your pain?

You do not look like you are in pain.

What would you like to try to alleviate your pain?

Answer and Explanation

The Correct Answer is D

Choice A reason: Offering narcotics immediately without assessing pain details or considering nonpharmacological options is not therapeutic. Pain management requires a tailored approach, evaluating pain characteristics and patient preferences, as narcotics carry risks like respiratory depression, especially post-surgery, necessitating cautious use.

Choice B reason: Dismissing pain based on stable vitals is not therapeutic. Pain is subjective, and normal vitals (e.g., 110/60 mmHg, 60 bpm) don’t negate severe pain. This response invalidates the patient’s experience, potentially eroding trust and delaying effective pain management.

Choice C reason: Stating the patient doesn’t look in pain is dismissive and non-therapeutic. Pain is subjective, and external appearance may not reflect internal experience, especially in stoic patients. This response risks undermining patient trust and delaying appropriate pain relief interventions.

Choice D reason: Asking what the patient wants to try is therapeutic, promoting patient-centered care. It validates the patient’s pain, encourages shared decision-making, and considers both pharmacological and nonpharmacological options, optimizing pain relief while respecting patient autonomy and preferences post-surgery.

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Correct Answer is A

Explanation

Choice A reason: Diarrhea causes significant fluid and electrolyte losses, particularly sodium, potassium, and bicarbonate, risking dehydration and acid-base imbalances. Monitoring these parameters is critical to prevent hypovolemia, arrhythmias, or metabolic acidosis, making it the priority intervention for patient stability.

Choice B reason: Standard precautions are necessary to prevent infection transmission but are a routine practice, not the priority. While important for safety, they do not address the immediate physiological threat of fluid and electrolyte imbalances caused by ongoing diarrhea.

Choice C reason: Identifying the cause of diarrhea and assessing bowel habits is important for long-term management but is secondary to stabilizing the patient. Fluid and electrolyte losses pose an immediate risk, requiring urgent monitoring before diagnostic or historical assessments.

Choice D reason: Encouraging small, frequent meals may help manage diarrhea long-term by reducing gastrointestinal irritation, but it is not the priority. Addressing fluid and electrolyte imbalances takes precedence to prevent life-threatening complications like dehydration or hypokalemia.

A. The patient who has a PCA running that needs the syringe replaced. B. The patient who needs to be pre-medicated before walking. C. The patient who is experiencing 8/10 pain and has an immediate order for pain medication D. The patient who needs to take a scheduled dose of maintenance pain medication

Correct Answer is C

Explanation

Choice A reason: Replacing a PCA syringe ensures continued pain control but is less urgent than acute severe pain. PCA systems often have residual medication, allowing a brief delay without compromising pain management, so this is not the priority.

Choice B reason: Pre-medicating before walking prevents pain exacerbation but is less critical than addressing existing severe pain. Scheduled mobility can be delayed slightly to prioritize acute needs, making this a lower priority intervention.

Choice C reason: A patient with 8/10 pain and an immediate order indicates acute, severe distress requiring urgent intervention. Severe pain can elevate stress hormones, heart rate, and blood pressure, necessitating prompt medication to stabilize the patient and alleviate suffering.

Choice D reason: Scheduled maintenance medication maintains baseline pain control but is not urgent compared to acute 8/10 pain. Delaying a scheduled dose briefly is less likely to cause harm than untreated severe pain, making this a lower priority.

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A nurse is caring for a patient who recently had abdominal surgery and is experiencing severe pain. The patient’s blood pressure is 110/60 mmHg, and heart rate is 60 beats/min. Additionally, the patient does not appear to be in any distress. Which response by the nurse is most therapeutic?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client admitted with diarrhea. Which of the following interventions would be a priority for this client?

Correct Answer is A

Explanation

The nurse is administering pain medication for several patients. Which patient does the nurse administer medication to first?

Correct Answer is C

Explanation

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A nurse is caring for a patient who recently had abdominal surgery and is experiencing severe pain. The patient’s blood pressure is 110/60 mmHg, and heart rate is 60 beats/min. Additionally, the patient does not appear to be in any distress. Which response by the nurse is most therapeutic?

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