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 C

Explanation

A. Dizziness is not typically associated with routine perineal care, so it is not a common concern for the caregiver to monitor during cleansing. Normal care does not usually affect blood pressure or circulation enough to cause dizziness.

B. The foreskin should be gently retracted in male clients who are uncircumcised to clean beneath it, as failing to do so can lead to buildup of secretions and increase the risk of infection. Proper retraction is important for hygiene and to prevent conditions like balanitis.

C. An erection may occur as a reflex response during perineal care, especially in males with intact neurologic function. Caregivers should be aware of this possibility and continue care calmly and professionally without assuming it is sexual in nature.

D. The pubic area does not need to be shaved for routine hygiene, and shaving can cause microabrasions that increase the risk of infection. Proper cleansing with soap and water is sufficient to maintain perineal hygiene.

A. Family attorney. B. Nurse manager. C. Hospice nurse. D. Chaplain.

Correct Answer is A

Explanation

A. A family attorney is the most appropriate professional to contact for more information about advance directives. Attorneys are knowledgeable about the legal aspects of advance directives, including living wills and durable power of attorney for healthcare, and can provide guidance on how to properly complete these documents.
B. A nurse manager may provide general information, but an attorney is more suited to address the legal aspects of advance directives.
C. A hospice nurse focuses on end-of-life care but may not have the expertise to provide comprehensive information about the legal requirements for advance directives.
D. A chaplain can offer spiritual support but is not the best resource for legal information regarding advance directives.

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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

The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?

Correct Answer is C

Explanation

During the admission process, a client requests more information about advance directives. Which professional should the nurse recommend the client contact?

Correct Answer is A

Explanation

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