A patient is 6 hours postoperative after abdominal surgery and complains of severe pain despite receiving prescribed pain medication. What should be the nurse's next course of action?
Document the patient's pain and notify the physician.
Encourage the patient to use non-pharmacologic methods like relaxation.
Administer a stronger dose of pain medication.
Perform a focused assessment of the surgical site and evaluate for any complications.
The Correct Answer is D
A. Document the patient's pain and notify the physician: While documentation and communication are necessary, the nurse must first gather objective assessment data to provide a meaningful report. Notifying the provider without a physical assessment prevents the identification of acute surgical complications. Physical assessment must always precede notification in the nursing process.
B. Encourage the patient to use non-pharmacologic methods like relaxation: While relaxation is a helpful adjunct, it is insufficient as a primary intervention for "severe" acute postoperative pain. Using only non-pharmacologic methods ignores the potential for serious surgical complications that require medical attention. This approach delays necessary diagnostic evaluation of the patient's distress.
C. Administer a stronger dose of pain medication: Administering more analgesia without an assessment is dangerous and could mask the symptoms of a worsening condition like hemorrhage or dehiscence. It violates safe practice standards by treating a symptom without investigating the underlying cause. Nurses cannot independently increase doses beyond prescribed limits.
D. Perform a focused assessment of the surgical site and evaluate for any complications: Severe pain that is refractory to standard analgesics can be an early warning sign of hematoma, infection, or internal injury. The nurse must inspect the dressing, check for distension, and monitor vital signs to rule out emergencies. Assessment is the critical first step in clinical decision-making.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Asthma:While asthma causes wheezing due to bronchoconstriction, it does not typically cause a global decrease in breath sounds unless the attack is severe and air movement is minimal. In many cases of asthma, breath sounds are audible but adventitious. Decreased sounds suggest a more significant barrier to air transmission.
B. Normal lung function:Normal lung function is characterized by clear, vesicular breath sounds in the periphery and bronchial sounds over the larger airways. Decreased or absent breath sounds are always an abnormal finding that requires further investigation. They indicate an interruption in the normal transmission of sound through the lung tissue.
C. Bronchitis:Bronchitis typically manifests as loud, coarse rhonchi or wheezes caused by mucus and inflammation in the large airways. Breath sounds are usually present but distorted by the adventitious noises. It does not typically result in the diminished intensity of sound associated with "decreased" breath sounds.
D. Pleural effusion:The accumulation of fluid in the pleural space acts as a physical barrier that dampens the transmission of sound from the lungs to the chest wall. This results in significantly diminished or absent breath sounds over the area of the effusion. It is a classic clinical finding for this pathological state.
Correct Answer is A
Explanation
A. Increase supplemental oxygen and reassess the patient:Restlessness and confusion are classic early clinical manifestations of cerebral hypoxia. Increasing the fraction of inspired oxygen immediately addresses the physiological deficit at the base of Maslow's hierarchy. Reassessment ensures the intervention is effective in improving oxygen saturation and mental status.
B. Apply restraints for patient safety due to restlessness:Restraints are a last resort and are contraindicated if the patient's behavior is caused by a treatable physiological crisis like hypoxia. Restricting movement can increase agitation and further increase oxygen demand. The priority must be treating the underlying cause of the restlessness.
C. Notify the family about the change in mental status:Informing the family is a communication task that follows immediate clinical intervention. It does not address the life-threatening lack of oxygen that is causing the confusion. The patient's physical stability must be managed before administrative or family communication occurs.
D. Document the findings and observe for further deterioration:Passive observation in the presence of early hypoxia allows the patient's condition to worsen into respiratory arrest. Documentation is a legal requirement but should never delay active nursing intervention for an acute physiological change. Immediate action is required to prevent further decline.
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