the nurse is caring for a client who is 4 hours post operative from abdominal surgery the client is complaining of severe pain what is the nurses firs
Logo

Nursing Elites

HESI LPN

Adult Health 1 Exam 1

1. The nurse is caring for a client who is 4 hours post-operative from abdominal surgery. The client is complaining of severe pain. What is the nurse's first action?

Correct answer: A

Rationale: The correct first action for the nurse to take when a post-operative client complains of severe pain is to reassess the pain and its characteristics. Reassessment is crucial to understand the nature and intensity of the pain, which will guide the nurse in providing appropriate interventions. Administering pain medication may be necessary but should only be done after reassessment to ensure the right medication and dose are given. Notifying the surgeon may be required in certain situations, but reassessment of pain should precede this action. Encouraging relaxation techniques is not the priority when a client is experiencing severe pain post-operatively.

2. A client with a diagnosis of chronic heart failure is receiving digoxin. What is the most important assessment before administering this medication?

Correct answer: B

Rationale: The correct answer is to assess the heart rate. Before administering digoxin, it is essential to evaluate the heart rate as digoxin can cause bradycardia. While checking blood pressure, monitoring respiratory rate, and measuring oxygen saturation are important assessments in the care of a client with chronic heart failure, assessing the heart rate is particularly critical due to the medication's potential impact on heart rhythm.

3. The nurse plans to administer the rubella vaccine to a postpartum client whose titer is < 1:8 and who is breastfeeding. What information should the nurse provide this client?

Correct answer: D

Rationale: Educating about the waiting period helps prevent possible rubella infection in a subsequent early pregnancy.

4. Based on the documentation in the medical record, which action should the nurse implement next?

Correct answer: B

Rationale: The correct answer is to observe the mother breastfeeding her infant. This action is essential to ensure that the infant is feeding well and to assess maternal-infant bonding. Administering the rubella vaccine subcutaneously (Option A) is not the immediate priority in this scenario as assessing breastfeeding is more crucial. Calling the nursery for the infant's blood type result (Option C) is premature and not the next appropriate step, as it does not address the immediate needs of the newborn. Administering Vicodin one tablet for pain (Option D) is not indicated without further assessment or indication of pain, making it an incorrect choice at this time.

5. The nurse is providing care for a client with a draining postoperative wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Which is the most important action for the nurse to take?

Correct answer: D

Rationale: Administering prescribed antibiotics is crucial in treating MRSA infections. MRSA is a type of bacteria that is resistant to many antibiotics, including methicillin. Therefore, prompt administration of the appropriate antibiotics is essential to target the MRSA infection effectively. Encouraging increased oral fluids (Choice A) and providing high-protein snacks (Choice B) may be beneficial for overall recovery but are not the most important actions in treating an MRSA infection. Changing the wound dressing (Choice C) is important for wound care but does not directly address the infection caused by MRSA.

Similar Questions

A client with gastroesophageal reflux disease (GERD) is being taught about dietary modifications. What should be emphasized?
A client with a history of peptic ulcer disease (PUD) is prescribed omeprazole (Prilosec). What is the primary action of this medication?
What intervention should the nurse implement for a client experiencing an anxiety attack?
A healthcare provider is conducting a health education session about the prevention of type 2 diabetes. What lifestyle modification should be emphasized?
The nurse is preparing a client for discharge following a myocardial infarction. What should the nurse prioritize in the discharge instructions?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses