On the second postoperative day, a client who had a colon resection is starting to eat and ambulate with assistance. Although the client has a prescription for an oral analgesic, they request that the PCA containing morphine be continued for one more day due to fear of pain. Which intervention is most important for the nurse to implement?
Measure urinary output to ensure renal functioning.
Administer the oral analgesic medication an hour before discontinuing the PCA pump.
Monitor for a depressed respiratory rate.
Teach about the need to progress to a high-fiber diet.
The Correct Answer is B
Choice A reason: Measuring urinary output is important for monitoring renal function, especially when using medications like morphine, but it is not the most critical intervention in this context.
Choice B reason: Administering the oral analgesic before discontinuing the PCA allows for the medication to take effect, preventing breakthrough pain and addressing the client's fear of pain.
Choice C reason: Monitoring for a depressed respiratory rate is crucial when a patient is on morphine, but the priority is to manage pain effectively as the client transitions to oral analgesics.
Choice D reason: Education on dietary needs is important for long-term recovery, but immediate pain management is a higher priority in the postoperative period.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Assuming care of the client and reassigning the PN does not address the immediate need to correct the client's position for the sigmoidoscopy.
Choice B reason: While assistance may be needed, it is more important to first ensure that the client is in the correct position for the procedure.
Choice C reason: Acknowledging the PN's action would be incorrect since the client has not been positioned safely and correctly for a sigmoidoscopy.
Choice D reason: Demonstrating the correct positioning ensures the procedure can be performed effectively and safely, which is the nurse's immediate responsibility.
Correct Answer is D
Explanation
Choice A reason: While obtaining satisfaction with appearance is an important long-term goal, it is not the first step in treatment. Addressing the behavior itself is crucial before tackling self-image issues.
Choice B reason: Achieving steady weight loss is a goal that will likely result from regulating food portions and other treatment interventions. It is not the initial focus when establishing treatment goals.
Choice C reason: Instituting an exercise plan is part of a comprehensive treatment plan but is secondary to establishing control over eating behaviors.
Choice D reason: Regulating food portions is essential for reducing the frequency and volume of binge eating episodes, which is the immediate concern in binge eating disorder management.
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