One hour after arriving on the postoperative unit, a woman who received spinal anesthesia 5 hours ago is complaining of severe abdominal incisional pain. Her vital signs are: temperature 99° F (37.2° C), heart rate 110 beats/minute, respiratory rate 30 breaths/minute and blood pressure 160/90 mmHg. The client's skin is pale, and the surgical dressing is dry and Intact. Which intervention is most important for the nurse to Implement?
Provide pillow for splinting.
Assess the IV site for patency.
Place in a high Fowler position.
Administer an IV analgesic.
None
None
The Correct Answer is D
The correct answer is Choice D
Choice A rationale: Splinting with a pillow may reduce discomfort during movement or coughing by stabilizing the incision site, but it does not address acute postoperative pain with sympathetic overdrive. The elevated heart rate, respiratory rate, and blood pressure suggest a stress response mediated by catecholamines. Without analgesia, nociceptive signals continue to activate the hypothalamic-pituitary-adrenal axis. While splinting is supportive, it lacks the pharmacologic efficacy needed to blunt nociceptive transmission at the spinal or supraspinal level.
Choice B rationale: Assessing IV patency is a procedural prerequisite for medication administration but not a therapeutic intervention in itself. It does not directly address the pathophysiology of acute pain or the sympathetic surge evidenced by tachycardia and hypertension. Pain activates ascending pathways via A-delta and C fibers, requiring pharmacologic blockade. IV access assessment is necessary but secondary to the urgent need for analgesia to prevent complications like hypoxia, hyperventilation, or delayed recovery.
Choice C rationale: High Fowler positioning may improve diaphragmatic excursion and reduce pulmonary complications, but it does not mitigate visceral or incisional pain. In fact, increased intra-abdominal pressure from upright posture may exacerbate pain at the surgical site. Pain perception involves central sensitization and peripheral nociceptor activation, which are unaffected by positioning. The client’s pale skin and elevated vitals indicate systemic distress requiring analgesic intervention, not postural adjustment. Thus, this choice lacks direct analgesic benefit.
Choice D rationale: IV analgesics act rapidly to inhibit nociceptive transmission at the spinal cord and brainstem levels. Opioids bind to mu receptors, reducing neurotransmitter release and hyperpolarizing neurons, thereby dampening pain signals. This intervention directly targets the physiologic cause of elevated heart rate, respiratory rate, and blood pressure. Normal heart rate is 60–100 bpm, respiratory rate 12–20 breaths/min, and BP <120/80 mmHg. Prompt analgesia prevents complications like hypoxia, delayed healing, and neuroendocrine stress
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
The correct answer isa. Place a bedside commode next to bed.,b. Measure neurological vital signs every 4 hours.,d. Encourage family to participate in the client’s care.
Choice A rationale:
Placing a bedside commode next to the bed helps prevent falls and promotes independence in toileting, which is crucial for stroke patients who may have mobility issues.
Choice B rationale:
Measuring neurological vital signs every 4 hours is essential to monitor for any changes in the patient’s condition, which can help in early detection of complications.
Choice C rationale:
Suctioning the oral cavity every 4 hours is not typically necessary unless the patient has specific issues with swallowing or secretion management.Routine suctioning can also cause discomfort and potential injury.
Choice D rationale:
Encouraging family to participate in the client’s care provides emotional support and helps in the rehabilitation process.Family involvement can improve the patient’s motivation and adherence to the rehabilitation plan.
Choice E rationale:
Playing classical music in the room can be soothing and beneficial for some patients, but it is not a standard intervention for stroke rehabilitation.The effectiveness of music therapy can vary based on individual preferences.
Correct Answer is B
Explanation
After retinal detachment surgery, it is crucial to protect the eye and the surgical repair site from accidental trauma or pressure. Providing an eye shield helps to shield the eye during sleep when the client may not have conscious control over their movements.
This can help prevent inadvertent rubbing or bumping of the eye, which could potentially disrupt the surgical repair and hinder the healing process.
Obtaining vital signs every 2 hours during hospitalization is a routine nursing intervention for postoperative care in general but is not specific to retinal detachment surgery. The frequency of vital sign monitoring may vary depending on the client's overall condition and the healthcare provider's orders.
Teaching a family member to administer eye drops may be necessary for the client's ongoing care, but it is not specifically related to the immediate postoperative period. Eye drop administration instructions can be provided as part of the client's discharge teaching.
Encouraging deep breathing and coughing exercises is a general postoperative intervention that promotes respiratory function and helps prevent complications such as pneumonia. While important for overall postoperative care, it is not specific to retinal detachment surgery.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today