For the past six hours, a postoperative male client has refused pain medication because he believed that he could "tough it out." When an opioid analgesic is administered, the client has difficulty obtaining a satisfactory level of comfort. Which action is best for the practical nurse (PN) to use in assisting this client to deal with his pain?
Dim the lights in the room and close the door.
Guide the client through slow, rhythmic breathing.
Turn the television on to the client's favorite show.
Obtain a prescription for a higher dose of pain medication.
The Correct Answer is B
This is the best action for the PN to use in assisting this client to deal with his pain because it provides a non-pharmacological method of pain relief that can enhance the effect of the opioid analgesic. Slow, rhythmic breathing can help the client relax, distract from the pain, and increase oxygenation and blood flow.
A. Dimming the lights in the room and closing the door may not be enough to help the client deal with his pain and may not address his psychological or emotional needs.
C. Turning the television on to the client's favorite show may not be effective in helping the client deal with his pain and may be distracting or irritating for him.
D. Obtaining a prescription for a higher dose of pain medication may not be necessary or appropriate for this client and may increase the risk of side effects or dependence. The PN should assess the client's pain level and response to the current dose before requesting a change in medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Ineffective airway clearance.
Choice A rationale:
Risk of infection is not the priority nursing problem in this scenario. While the darkened membranes and smoky breath may be indicative of potential infection, addressing ineffective airway clearance is more urgent as it directly impacts the client's breathing and oxygenation.
Choice B rationale:
Ineffective airway clearance should be the priority nursing problem. Darkened membranes of the mouth and smoky breath suggest possible inhalation injury or airway obstruction.
Maintaining a patent airway is crucial for adequate oxygenation and to prevent further complications.
Choice C rationale:
Acute pain is not the priority nursing problem in this case. Although it is essential to address any discomfort the client may be experiencing, it takes a back seat to the more critical issue of ineffective airway clearance.
Choice D rationale:
Disturbed body image is not the priority nursing problem when the client has darkened mouth membranes and smoky breath. While it is important to address body image concerns, the immediate focus should be on managing and improving the client's airway clearance.
Correct Answer is D
Explanation
Choice A rationale: While it is important to monitor the fetal heart rate, it does not directly address the client's immediate need to empty her bladder.
Choice B rationale: Obtaining a straight catheter kit to empty her bladder could be considered if the client is unable to void on her own, but it is not the first line of action if the client is able to ambulate.
Choice C rationale: Checking the perineum for changes in "show" or discharge is part of ongoing labor monitoring, but it does not address the client's immediate request.
Choice D rationale: Assisting the client up to the bathroom is appropriate. Ambulating to the bathroom is safe given the unchanged vaginal exam, and allowing the client to empty her bladder can help maintain bladder function and comfort.
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