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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: While developing new screening protocols is a positive step, it does not directly measure the effectiveness of the prevention program in terms of client outcomes or behavior change.
Choice B reason: Early diagnosis of at-risk clients is important, but it is a secondary measure of effectiveness that follows education and behavior change, which are primary prevention strategies.
Choice C reason: Prompt rehabilitation for clients with disease complications is a form of tertiary prevention and does not reflect the effectiveness of the primary prevention program.
Choice D reason: Improvement in client knowledge about specific risk factors as evidenced by test scores is a direct measure of the effectiveness of an educational prevention program. It indicates that clients have understood and potentially internalized the information necessary to prevent sexually transmitted diseases, which is the goal of primary prevention.
Correct Answer is C
Explanation
Choice A reason: A thick, dry, and dark area on bilateral heels may indicate the beginning stages of a pressure ulcer, but it is not the earliest sign. The earliest indication is usually a non-blanchable redness over a bony prominence.
Choice B reason: Broken skin without evidence of undermining could be a sign of a pressure ulcer, but it is not the earliest indication. The earliest sign is persistent redness over an area of pressure.
Choice C reason: A defined area of persistent redness over bone, especially if it does not blanch when pressed, is the earliest indication of a pressure ulcer. This stage is known as a Stage 1 pressure injury.
Choice D reason: A superficial sacral ulcer with defined margins indicates that a pressure ulcer has already developed and is not the earliest sign of its development.
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