The nurse is providing postoperative care for a client who complains of severe pain after receiving codeine 30 mg orally one hour ago.
Which intervention should the nurse implement next?

Ask the UAP to offer back rubs to the client.

Reassess the client and the level of pain.

Encourage the client to focus on taking deep breaths.

Tell the client the medication needs more time to work.

Answer and Explanation

The Correct Answer is B

The nurse should reassess the client’s pain level and determine if additional interventions are needed to manage the pain.

Choice A is not the answer because while a back rub may provide some temporary relief, it does not address the underlying cause of the pain.

Choice C is not the answer because while deep breathing can help with relaxation, it does not address the underlying cause of the pain.

Choice D is not the answer because telling the client that the medication needs more time to work does not address their current pain level or provide any immediate relief.

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Correct Answer is D

Explanation

Requesting military records by phone without the patient’s consent would be a breach of confidentiality.

Choice A is incorrect because sharing the health history with a case manager who is involved in the patient’s care would not be a breach of confidentiality.

Choice B is incorrect because discussing diagnoses with a physical therapist who is involved in the patient’s care would not be a breach of confidentiality.

Choice C is incorrect because providing a list of food allergies to nutritional services who are involved in the patient’s care would not be a breach of confidentiality.

A. Places food on the unaffected side of the mouth. B. Raises the head of the bed to 80 degrees. C. Positions the head with the chin tilted slightly downward. D. Allows 30 minutes of rest before feeding.

Correct Answer is B

Explanation

A. Placing food on the unaffected side of the mouth is appropriate for a client who has had a CVA and may have unilateral weakness. This technique helps the client chew and swallow effectively, reducing the risk of aspiration.

B. Raising the head of the bed to 80 degrees is too high and can increase the risk of choking or aspiration by making it harder for the client to control the food bolus during swallowing. A more appropriate position is raising the head of the bed to 45–60 degrees, which facilitates safe swallowing while maintaining comfort. This action requires additional teaching.

C. Positioning the head with the chin tilted slightly downward, known as the chin-tuck position, is a recommended strategy to prevent aspiration. This position helps close the airway during swallowing, reducing the risk of food or liquid entering the trachea.

D. Allowing 30 minutes of rest before feeding is appropriate because it ensures the client is not fatigued, which can compromise swallowing ability and increase the risk of aspiration.

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The nurse is providing postoperative care for a client who complains of severe pain after receiving codeine 30 mg orally one hour ago. Which intervention should the nurse implement next?

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The nurse is providing postoperative care for a client who complains of severe pain after receiving codeine 30 mg orally one hour ago.
Which intervention should the nurse implement next?