Nokea
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.
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When turning a male client who has been lying on his back for 2 hours, the nurse notes that the skin over his sacrum is very white. The client is repositioned and when the nurse reassesses the sacrum 2 hours later, the area is bright red. Which intervention should the nurse implement?
- A. Apply a warm compress to the sacral area.
- B. Wash the area with soap and water.
- C. Reassess and turn the client in 30 minutes.
- D. Massage the reddened area with lotion.
Correct Answer: C
Rationale: Frequent turning prevents pressure ulcers by relieving pressure.
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 suggests respiratory issues, needing immediate assessment.
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.
During the admission process, a client requests more information about advance directives. Which professional should the nurse recommend the client contact?
- A. Family attorney.
- B. Nurse manager.
- C. Hospice nurse.
- D. Chaplain.
Correct Answer: A
Rationale: Attorney provides legal guidance on advance directives.
To assess a client's dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes, but does not feel a pulsation. Which action should the nurse take next?
- A. Reduce the amount of pressure being applied on the top of the foot.
- B. Palpate the site on the inner side of the ankle below the medial malleolus.
- C. Obtain a doppler stethoscope to auscultate the pulse at the same site.
- D. Document in the nurses' notes that the dorsalis pedis pulse is not palpable.
Correct Answer: A
Rationale: Reducing pressure may reveal the pulse.