The nurse is caring for a client who is still experiencing light sedation after undergoing an emergency colectomy for bowel obstruction. Which postoperative pain intervention should the nurse implement first?

Provide the first medication prescribed for pain management.

Review medical records to obtain pain tolerance expectations.

Wait until the client is awake before providing pain management.

Attempt to obtain a self-report of pain level from the client.

Answer and Explanation

The Correct Answer is A

Choice A reason: Providing the first medication prescribed for pain management is the best intervention that the nurse can implement first, because it can prevent the escalation of pain and reduce the need for higher doses later. The nurse should follow the principles of pain management, such as administering analgesics before pain becomes severe, using a multimodal approach, and individualizing the plan of care.

Choice B reason: Reviewing medical records to obtain pain tolerance expectations is not a priority intervention that the nurse should implement first, because it may not reflect the current pain level or needs of the client. Pain tolerance is influenced by many factors, such as culture, age, gender, and previous experiences, and it may vary from person to person and from situation to situation.

Choice C reason: Waiting until the client is awake before providing pain management is not a recommended intervention that the nurse should implement first, because it can lead to inadequate pain relief and delayed recovery. The nurse should not assume that the client is not in pain because of sedation, but should use other indicators, such as vital signs, facial expressions, and body movements, to assess pain.

Choice D reason: Attempting to obtain a self-report of pain level from the client is not a feasible intervention that the nurse should implement first, because the client may not be able to respond due to sedation. The nurse should use a valid and reliable pain assessment tool that is appropriate for the client's condition, such as the Behavioral Pain Scale (BPS) or the Critical-Care Pain Observation Tool (CPOT), to measure pain.

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Correct Answer is C

Explanation

Choice A reason: Obtaining a prostate-specific antigen blood level test is not a way to reduce risk factors for BPH, but a way to screen for prostate cancer, which is a different condition. Prostate-specific antigen (PSA) is a protein produced by the prostate gland, and its level may be elevated in men with prostate cancer or other prostate problems, such as BPH or prostatitis. However, PSA testing is not recommended for all men, and it has some limitations and risks. The nurse should discuss the benefits and harms of PSA testing with the client and help him make an informed decision.

Choice B reason: Taking vitamin supplements is not a proven way to reduce risk factors for BPH, and it may have some adverse effects, such as interactions with medications or increased bleeding. There is no clear evidence that any specific vitamin or mineral can prevent or treat BPH, and some studies have suggested that high doses of certain vitamins, such as vitamin E or folic acid, may increase the risk of prostate cancer. The nurse should advise the client to eat a balanced diet that includes fruits, vegetables, whole grains, and lean proteins, and to consult a doctor before taking any supplements.

Choice C reason: Increasing physical activity is a beneficial way to reduce risk factors for BPH, as well as to improve overall health and well-being. Physical activity can help maintain a healthy weight, lower blood pressure, reduce inflammation, and enhance blood flow to the pelvic area, which may prevent or delay the development of BPH. The nurse should encourage the client to engage in moderate-intensity aerobic exercise, such as brisk walking, cycling, or swimming, for at least 150 minutes per week, and to include some strength training and flexibility exercises as well.

Choice D reason: Consuming a high protein diet is not a helpful way to reduce risk factors for BPH, and it may have some negative effects, such as increasing the risk of kidney stones, gout, or osteoporosis. A high protein diet may also increase the intake of saturated fat, cholesterol, and sodium, which can raise the risk of cardiovascular disease and hypertension, which are also risk factors for BPH. The nurse should advise the client to limit the intake of animal protein, such as red meat, poultry, eggs, and dairy products, and to choose plant-based protein sources, such as beans, nuts, seeds, and soy products, more often.

A. Apical heart rate of 100 to 110 beats/minute. B. Redness and edema noted at the incision site. C. High-pitched sound heard upon inspiration. D. Pain rating of 8 on a scale of 1 to 10.

Correct Answer is C

Explanation

Choice A reason: An apical heart rate of 100 to 110 beats/minute is not unusual after surgery, as the client may be experiencing stress, pain, or anxiety. This finding does not require immediate action by the nurse, but should be monitored and reported if it persists or worsens.

Choice B reason: Redness and edema at the incision site are expected signs of inflammation and healing after surgery. This finding does not require immediate action by the nurse, but should be assessed for signs of infection, such as pus, warmth, or foul odor.

Choice C reason: A high-pitched sound heard upon inspiration, also known as stridor, is a sign of upper airway obstruction, which can be life-threatening. This finding requires immediate action by the nurse, such as administering oxygen, suctioning, or calling for help.

Choice D reason: A pain rating of 8 on a scale of 1 to 10 indicates severe pain, which can affect the client's recovery and comfort. This finding requires prompt action by the nurse, such as administering analgesics, repositioning, or providing non-pharmacological interventions. However, this is not as urgent as choice C, which involves the client's airway.

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The nurse is caring for a client who is still experiencing light sedation after undergoing an emergency colectomy for bowel obstruction. Which postoperative pain intervention should the nurse implement first?

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