Twelve hours following a unilateral total knee replacement, a client reports being unable to sleep because of severe incisional pain. What is the best initial nursing action?

Instruct the client in use of the prescribed patient-controlled analgesia (PCA) pump.

Assist the client in assuming a lateral recumbent position for comfort.

Initiate continuous passive motion (CPM) to relieve muscle spasms.

Apply ice to the incision for twenty minutes prior to joint flexion exercises.

Answer and Explanation

The Correct Answer is A

A. Instructing the client in the use of the PCA pump directly addresses the severe pain by allowing the client to self-administer analgesia as needed, which provides immediate relief and is crucial for effective pain management post-surgery.
B. Assisting the client in changing positions may offer temporary relief but does not address the underlying pain, which should be managed primarily through medication.
C. Initiating CPM is not an appropriate first step for managing severe pain. CPM is used for improving joint mobility and should only be considered after effective pain management is established.
D. Applying ice might provide some temporary relief, but it is not a substitute for effective pain control through medication. Addressing the pain with PCA is the priority.

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Correct Answer is D

Explanation

A. Muscle strength and tone are important assessments but are not directly related to the safe use of a heating pad.
B. The rebound phenomenon, where the effects of heat application reverse after prolonged exposure, is a consideration, but not as crucial as assessing for neurosensory impairment.
C. Limitations to range of motion may be important for mobility assessments but are less relevant to the safe application of heat therapy.
D. Assessing the degree of neurosensory impairment is most important before applying a heating pad. If the client has impaired sensation, they may not be able to detect if the heating pad is too hot, which could lead to burns or other injuries.

A. Review the intake and output record. B. Give the client 8 ounces of water to drink. C. Notify the healthcare provider. D. Check the drainage tubing for a kink.

Correct Answer is D

Explanation

A. Reviewing the intake and output record is important for overall assessment but does not address the immediate issue of low urine output.
B. Giving the client water might be appropriate if the low output is related to dehydration, but the first step is to investigate possible mechanical issues with the catheter.
C. Notifying the healthcare provider might be necessary if there is a persistent problem, but it is important first to identify and address any immediate issues with the catheter.
D. Checking the drainage tubing for a kink is the first step to ensure that the catheter is functioning properly. Mechanical obstruction can cause reduced urine output and should be assessed before taking further actions.

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Twelve hours following a unilateral total knee replacement, a client reports being unable to sleep because of severe incisional pain. What is the best initial nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

Correct Answer is D

Explanation

The nurse receives a report that a client with an indwelling urinary catheter has an output of 150 mL for the previous 8-hour shift. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

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