Nokea
The nurse is caring for a client in acute pain as a result of surgery. Which intervention should the nurse implement?
- A. Administer pain medication as soon as the time frame allows.
- B. Use nonpharmacological methods to replace medications.
- C. Use cryotherapy after heat therapy because it works faster.
- D. Instruct family members to administer medication with the PCA.
Correct Answer: A
Rationale: Administering pain medication PRN within time frames ensures timely relief, per pain management standards. Nonpharmacological methods supplement, cryotherapy timing varies, and family PCA use is unsafe.
You may also like to solve these questions
Which action by the client indicates to the nurse preoperative teaching has been effective?
- A. The client demonstrates how to use the incentive spirometer device.
- B. The client demonstrates the use of the patient-controlled analgesia pump.
- C. The client can name two (2) anesthesia agents used during surgery.
- D. The client ambulates down the hall to the nurse's station each hour.
Correct Answer: A
Rationale: Using the incentive spirometer correctly prevents atelectasis, a key preoperative teaching goal. PCA use is postoperative, naming agents is unnecessary, and hourly ambulation is excessive.
The client in the surgery holding area identifies the left arm as the correct surgical site, but the operative permit designates surgery to be performed on the right arm. Which interventions should the nurse implement? Select all that apply.
- A. Review the client's chart.
- B. Notify the surgeon.
- C. Immediately call a 'time-out.'
- D. Correct the surgical permit.
- E. Request the client mark the left arm.
Correct Answer: A,B,C
Rationale: Reviewing the chart verifies the correct site, notifying the surgeon addresses the discrepancy, and calling a time-out ensures team confirmation. Correcting the permit or marking the wrong site is unsafe.
Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia?
- A. Loss of sensation at the lumbar (L5) dermatome.
- B. Absence of the client's posterior tibial pulse.
- C. The client has a respiratory rate of eight (8).
- D. The blood pressure is within 20% of the client's baseline.
Correct Answer: C
Rationale: A respiratory rate of 8 suggests respiratory depression, a serious spinal anesthesia complication. L5 numbness is expected, absent pulse suggests vascular issues, and stable BP is normal.
The unlicensed assistive personnel (UAP) can be overheard talking loudly to the scrub technologist discussing a problem which occurred during one (1) of the surgeries. Which intervention should the nurse in the surgical holding area with a female client implement?
- A. Close the curtains around the client's stretcher.
- B. Instruct the UAP and scrub tech to stop the discussion.
- C. Tell the surgeon on the case what the nurse overheard.
- D. Inform the client the discussion was not about her surgeon.
Correct Answer: B
Rationale: Instructing the UAP and tech to stop protects patient privacy and reduces anxiety, per HIPAA. Curtains, informing the surgeon, or reassuring the client are less direct.
The nurse received a report the elderly postoperative client became confused during the previous shift. Which client problem would the nurse include in the plan of care?
- A. Risk for injury.
- B. Altered comfort level.
- C. Impaired circulation.
- D. Impaired skin integrity.
Correct Answer: A
Rationale: Confusion increases fall and injury risk, the priority problem in elderly postoperative clients. Comfort, circulation, and skin integrity are secondary.