A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the postanasthesia unit. Before selecting which medication to administer, which action should the nurse implement?

Correct Answer: C

Rationale: In this scenario, the correct action for the nurse to implement before selecting which medication to administer is to compare the client's pain scale rating with the prescribed dosing (Option C). This is important because it ensures that the nurse is administering the appropriate medication based on the client's level of pain and the prescribed dosing guidelines. Option A is incorrect because while documenting the client's report of pain is important, it does not directly address the immediate need to select the appropriate medication. Option B is incorrect because focusing solely on the onset of action overlooks the individualized aspect of pain management based on the client's current pain level. Option D is incorrect as it puts the responsibility on the client to choose the medication, which is not appropriate in a healthcare setting. In an educational context, understanding the importance of assessing pain levels, comparing them with prescribed dosages, and following protocol for medication administration is crucial for providing safe and effective care to pediatric patients postoperatively. This rationale highlights the significance of individualized and evidence-based practice in pharmacological management in pediatric nursing.

Correct Answer: D

Rationale: In this scenario, the correct intervention is to provide the client with oral swabs to moisten his mouth (Option D). This intervention is appropriate because it helps alleviate the sensation of thirst and provides some relief to the client without compromising the fluid restriction orders. Option A is incorrect because removing all sources of liquids from the client's room may lead to increased frustration and non-compliance. Option B is incorrect as allowing ice chips still adds to the overall fluid intake, which goes against the prescribed restriction. Option C is incorrect as restricting family visits is not necessary and does not address the client's thirst concern. Educationally, this scenario highlights the importance of adhering to prescribed treatment plans, even if the client expresses frustration or discomfort. It also emphasizes the role of nursing interventions in managing patient care and comfort within the constraints of medical orders. Providing oral swabs can be a simple yet effective way to address the client's needs while maintaining therapeutic restrictions.

Correct Answer: C

Rationale: In this scenario, the correct intervention is to prepare a dose of epinephrine (Adrenalin) because the client is exhibiting signs of an allergic reaction to the contrast medium used in the CT scan. Epinephrine is the drug of choice in managing anaphylaxis, a severe allergic reaction that can manifest with symptoms like shortness of breath and itching. Administering epinephrine promptly can help reverse the allergic response and prevent further complications. Option A, calling respiratory therapy for a breathing treatment, is not the most appropriate action in this case because the client is experiencing an allergic reaction that requires immediate intervention with epinephrine. Option B, sending another nurse for an emergency tracheotomy set, is unnecessary and not indicated based on the client's presentation of symptoms. Option D, reviewing the client's complete list of allergies, while important for long-term management, is not the most urgent action to take when the client is currently experiencing an acute allergic reaction. Educationally, this question highlights the importance of recognizing and promptly managing allergic reactions, especially in healthcare settings where contrast media and other allergens are commonly used. Nurses should be knowledgeable about the signs and symptoms of allergic reactions and the appropriate interventions to ensure patient safety and well-being.

Correct Answer: C

Rationale: In this scenario, the correct answer is option C) Use an automated BP machine to monitor for hypotension. Rationale: Monitoring the blood pressure after administering an antihypertensive IV medication is crucial to ensure the medication effectively lowers the client's high blood pressure without causing a sudden drop leading to hypotension. Monitoring for hypotension is essential to prevent complications such as dizziness, fainting, or inadequate perfusion to vital organs. Option A) Measure urine output hourly to assess for renal perfusion may be important in the long term, but it is not the most immediate concern in this situation. Option B) Request a prescription for pain medication is not relevant to the client's current presentation of high blood pressure and associated symptoms. Option D) Provide a quiet environment with low lighting, although beneficial for overall patient comfort, is not the most critical intervention at this moment when dealing with a hypertensive crisis. Educational Context: Understanding the importance of monitoring vital signs, especially blood pressure, is crucial in pediatric nursing, as children can be more sensitive to changes in blood pressure. This scenario highlights the significance of prompt assessment and monitoring in managing hypertensive emergencies in pediatric patients to prevent adverse outcomes. Nurses need to prioritize interventions based on the client's immediate needs to ensure safe and effective care delivery.

Correct Answer: C

Rationale: In this scenario, the correct action for the nurse to implement first is option C, which is to auscultate the client's abdomen. Auscultation is crucial in assessing bowel sounds and identifying potential complications such as postoperative ileus. Option A, encouraging the client to ambulate, could be beneficial in some cases to promote peristalsis and prevent complications like deep vein thrombosis. However, in this specific situation with abdominal pain and distention, auscultation takes precedence. Offering ice chips or warm liquids (option B) may be appropriate for hydration and comfort but does not address the underlying cause of the symptoms. Assessing the client's temperature (option D) is important but is not the priority in this situation. The focus should be on assessing bowel function and potential surgical complications. Educationally, this question highlights the importance of prioritizing nursing interventions based on the client's presenting symptoms and the need to assess for postoperative complications promptly. Understanding the rationale behind prioritizing auscultation in this case can help nurses make critical decisions in clinical practice to ensure optimal patient outcomes.