For a client who is crying and seems agitated after major abdominal surgery, which action should a nurse take to establish a nursing diagnosis of pain related to an abdominal incision?
Continue to observe the client.
Ask the client to describe the discomfort.
Encourage the client to progressively relax all muscle groups.
Administer the prescribed analgesic and document the client’s response.
The Correct Answer is B
Ask the client to describe the discomfort. This is the best action to establish a nursing diagnosis of pain related to an abdominal incision because it allows the nurse to assess the location, intensity, quality, and duration of the pain, as well as any factors that aggravate or relieve it.
This information can help the nurse to plan appropriate interventions and evaluate their effectiveness.
Choice A. Continue to observe the client is wrong because it does not address the client’s pain or communicate empathy. The nurse should not ignore or minimize the client’s pain, but rather acknowledge it and offer assistance.
Choice C. Encourage the client to progressively relax all muscle groups is wrong because it is a nonpharmacological intervention that may help to reduce pain, but it does not establish a nursing diagnosis of pain. The nurse should first assess the client’s pain before implementing any interventions.
Choice D. Administer the prescribed analgesic and document the client’s response is wrong because it is a pharmacological intervention that may help to relieve pain, but it does not establish a nursing diagnosis of pain. The nurse should first assess the client’s pain before administering any medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The proper length of the needle to administer a subcutaneous injection depends on the amount of adipose tissue over the muscle.
The needle should be long enough to reach the subcutaneous layer but not so long that it penetrates the muscle. The needle gauge and length vary depending on the patient’s size and the injection site
Choice A is wrong because the age of the client does not determine the needle length.
However, age may affect the amount of adipose tissue and muscle mass, which are factors to consider when choosing a needle length.
Choice B is wrong because the viscosity of the solution does not determine the needle length. However, viscosity may affect the needle gauge, which is the diameter of the needle.
Thicker solutions may require larger gauge needles to allow easier flow.
Choice D is wrong because the quantity of the solution does not determine the needle length.
However, quantity may affect the syringe size, which is the volume of medication that can be held by the syringe.
The syringe size should match the prescribed dose as closely as possible to ensure accuracy and ease of measurement.
Correct Answer is C
Explanation
This is because furosemide is a diuretic that makes you pee more and lose water and electrolytes such as potassium and sodium.
Therefore, you should avoid foods that are high in sodium or potassium, such as bananas, oranges, cranberries, and bagels with cream cheese.
You should also drink plenty of fluids to prevent dehydration.
Choice A is wrong because oatmeal with a banana, milk, and orange juice contains too much potassium, which can cause irregular heartbeat or muscle weakness when taking furosemide.
Choice B is wrong because blueberry muffins, cranberry juice, and herbal tea contain too much sodium and sugar, which can raise your blood pressure and worsen your heart failure.
Choice D is wrong because a bagel with low-fat cream cheese and decaffeinated coffee contains too much sodium and caffeine, which can cause fluid retention and increase your heart rate.
Normal ranges for potassium are 3.5 to 5.0 mmol/L and for sodium are 135 to 145 mmol/L.
You should monitor your electrolyte levels regularly when taking furosemide.
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