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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Transporting the client without protective equipment would not comply with droplet precaution protocols and could pose a risk of infection to others.
B. Placing goggles over the eyeglasses is not necessary if a surgical mask can be properly fitted, as the mask itself provides the needed protection for droplet precautions.
C. A fitted respirator-style mask is typically not required for droplet precautions; a surgical mask is sufficient.
D. Securing a surgical face mask over the bridge of the client's nose just below the eyeglasses ensures that the mask is properly fitted, providing adequate protection while allowing the client to wear their eyeglasses comfortably. This approach adheres to droplet precaution protocols.
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.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.