By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?

Change the plan of care to provide different pain relief interventions

Reassess the client to determine the reasons for inadequate pain relief

Teach the client about the plan of care for managing his pain

Wait to see whether the pain lessens during the next 24hours

Answer and Explanation

The Correct Answer is B

A. Change the plan of care to provide different pain relief interventions:

While changing the plan of care may be necessary, it should be based on a thorough reassessment. Simply changing the plan without understanding the reasons for inadequate pain relief may not lead to effective outcomes.

B. Reassess the client to determine the reasons for inadequate pain relief.

Reassessment is a crucial step in the nursing process, especially when the desired outcomes are not achieved. By reassessing the client, the nurse can identify any factors contributing to the inadequate pain relief. This might include reevaluating the effectiveness of the current pain relief interventions, ensuring proper administration of medications, considering changes in the client's condition, or exploring any new factors affecting pain.

C. Teach the client about the plan of care for managing his pain:

Teaching is an important aspect, but in this case, reassessment takes precedence. Once the reasons for inadequate pain relief are determined, teaching can be tailored to address specific needs.

D. Wait to see whether the pain lessens during the next 24 hours:

If the pain is not adequately controlled, waiting for another 24 hours without action may prolong the client's discomfort and delay appropriate interventions. Reassessment and prompt adjustments to the plan of care are crucial for effective pain management.

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Correct Answer is C

Explanation

A. Comatose:

Coma refers to a state of deep unconsciousness where the individual is unresponsive to stimuli, including pain or external stimulation. In the scenario described, the patient is not comatose because they can be awakened by gentle shaking and calling their name.

B. Awake and alert:

This term describes a state of full alertness and responsiveness to the environment. The patient in the scenario is not fully awake and alert since they appear drowsy most of the time and require external stimuli to be awakened.

C. Lethargic:

Lethargy is characterized by drowsiness, reduced alertness, and a sluggish response to stimuli. In the scenario, the patient is described as drowsy most of the time but can be awakened by gentle shaking and calling their name. This aligns with the characteristics of lethargy.

D. Stuporous:

Stupor is a state of reduced responsiveness where the individual can be aroused only by vigorous or painful stimuli. The patient in the scenario does not fit the criteria for stupor as they can be awakened by gentle shaking and calling their name.

A. Performs auscultation between meals B. Clamps the Naso Gastric tube during auscultation C. Palpates the abdomen prior to performing auscultation. D. Auscultates bowel sounds for 3 to 5 min

Correct Answer is C

Explanation

A. Performs auscultation between meals:

Auscultating bowel sounds between meals is suitable as it allows for better detection of bowel sounds when digestion is not actively occurring.

B. Clamps the Naso Gastric tube during auscultation

Clamping the Naso Gastric (NG) tube during auscultation is appropriate. The NG tube when unclamped allows the free passage of air and fluid through the gastrointestinal tract. This could interfere with the natural sounds produced by the movement of air and fluid in the intestines, potentially leading to inaccurate assessment of bowel sounds.

C. Palpates the abdomen prior to performing auscultation:

Palpating the abdomen before auscultation may interfere with normal bowel sounds

D. Auscultates bowel sounds for 3 to 5 min:

Auscultating bowel sounds for a sufficient duration (3 to 5 minutes) is appropriate to comprehensively assess the presence, frequency, and character of bowel sounds.

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By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nursing instructor is observing a nursing student auscultating a client’s bowel sounds. Which of the following actions might require the instructor’s intervention?

Correct Answer is C

Explanation

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