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Which nursing intervention is the highest priority when administering pain medication to a client experiencing acute pain?
- A. Monitor the client's vital signs.
- B. Verify the time of the last dose.
- C. Check for the client's allergies.
- D. Discuss the pain with the client.
Correct Answer: C
Rationale: Checking allergies prevents adverse reactions, the highest safety priority. Vital signs, timing, and pain discussion follow.
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The postoperative client complains of hearing a 'popping sound' and feeling 'something opening' when ambulating in the room. Which intervention should the nurse implement first?
- A. Notify the surgeon the client has had an evisceration.
- B. Contact the surgery department to prepare for emergency surgery.
- C. Assess the operative site and cover the site with a moistened dressing.
- D. Explain this is a common feeling and tell the client to continue with activity.
Correct Answer: C
Rationale: A popping sound and opening sensation suggest dehiscence or evisceration; assessing and covering with a moist dressing stabilizes the site, the first step. Notification and surgery prep follow, and dismissing the symptom is unsafe.
Which nursing intervention has the highest priority when preparing the client for a surgical procedure?
- A. Pad the client's elbows and knees.
- B. Apply soft restraint straps to the extremities.
- C. Prepare the client's incision site.
- D. Document the temperature of the room.
Correct Answer: C
Rationale: Preparing the incision site ensures asepsis, reducing infection risk, the highest priority. Padding, restraints, and room temperature are secondary.
The nurse requests the client to sign a surgical informed consent form for an emergency appendectomy. Which statement by the client indicates further teaching is needed?
- A. I will be glad when this is over so I can go home today.
- B. I will not be able to eat or drink anything prior to my surgery.
- C. I can practice relaxing by listening to my favorite music.
- D. I will need to get up and walk as soon as possible.
Correct Answer: A
Rationale: Emergency appendectomy requires postoperative recovery, typically 1–2 days in hospital, so expecting to go home today indicates misunderstanding. NPO status, relaxation, and early ambulation are correct.
Which nursing intervention is priority for the client experiencing acute pain?
- A. Assess the client's verbal and nonverbal behavior.
- B. Wait for the client to request pain medication.
- C. Administer the pain medication on a scheduled basis.
- D. Teach the client to use only imagery every hour for the pain.
Correct Answer: A
Rationale: Assessing verbal and nonverbal behavior determines pain severity and guides treatment, the priority. Waiting, scheduled dosing, or imagery alone delays or limits care.
The client is complaining of left shoulder pain. Which intervention should the nurse implement first?
- A. Assess the neurovascular status of the left hand.
- B. Check the medication administration record (MAR).
- C. Ask if the client wants pain medication.
- D. Administer the client's pain medication.
Correct Answer: A
Rationale: Assessing neurovascular status rules out referred pain from cardiac or vascular issues, the priority per ABCs. MAR checks, asking about medication, and administration follow.