Nokea
A client who is 2 days postoperative for thoracic surgery is reporting incisional pain 2 hours after receiving pain medication. The client rates the pain as 5 on a pain scale of 1 to 10. After placing a call to the healthcare provider, which action should the nurse implement?
- A. Instruct the client to use guided imagery and slow rhythmic breathing.
- B. Place a hot water circulation device, such as an Aqua K pad, to the operative site.
- C. Tune to a television show or easy listening music to provide distraction.
- D. Provide at least 20 minutes of back massage and gentle effleurage.
Correct Answer: A
Rationale: Guided imagery promotes relaxation to manage moderate pain.
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The nurse learns that members of the nursing staff are uncomfortable with responding to client family members who are angry. While designing a teaching session to help the staff respond more effectively in these situations, which instructional strategy is best for the nurse to use?
- A. Journaling
- B. Return demonstration.
- C. Role playing.
- D. Analogies.
Correct Answer: C
Rationale: Role-playing builds confidence in handling anger.
The nurse has removed a barbiturate capsule from the unit dose wrapper to administer to a client. The client decides to watch a television program and requests not to take the medication. Which action should the nurse implement?
- A. Keep the medication and see if the client will want to take it later.
- B. Credit the medication back and put it in the client's medication box.
- C. Explain that since the medication is a controlled substance it must be taken.
- D. Have another nurse watch the disposal of the medication into the disposal container.
Correct Answer: D
Rationale: Witnessed disposal ensures safety and compliance.
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?
- A. Instruct the client in use of the prescribed patient-controlled analgesia (PCA) pump.
- B. Assist the client in assuming a lateral recumbent position for comfort.
- C. Initiate continuous passive motion (CPM) to relieve muscle spasms.
- D. Apply ice to the incision for twenty minutes prior to joint flexion exercises.
Correct Answer: A
Rationale: PCA pump allows self-administered analgesia for immediate pain relief.
During the admission assessment to the hospital, a male client reports that he is allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?
- A. Send a list of medication allergies to the pharmacy.
- B. Secure an allergy bracelet around the client's wrist.
- C. Notify the dietary department of the client's fruit allergy.
- D. Place a latex-free supply cart outside the client's room.
Correct Answer: B
Rationale: Allergy bracelet ensures immediate awareness.
The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?
- A. Temperature.
- B. Blood pressure.
- C. Heart rate.
- D. Respiratory rate.
Correct Answer: D
Rationale: Cyanosis indicates oxygenation issues, requiring respiratory assessment.