Level: Advanced
Difficulty: Hard
Subtopic: Pain basics
NCLEX: A 55-year-old client after abdominal surgery is being evaluated for nursing care related to pain basics. Assessme…
Nursing fundamentals Basic Care and Comfort Safety and Infection Prevention and Control
Case Study
A 55-year-old client after abdominal surgery is being evaluated for nursing care related to pain basics. Assessment data include temperature 100.8°F (38.2°C) with rigors and chills. Which intervention best reduces the client's risk of complications?
Question
A. Restrict all movement without individualized assessment.
B. Delay teaching until the day of discharge only.
C. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
D. Ignore small changes until they become severe.
B. Delay teaching until the day of discharge only.
C. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
D. Ignore small changes until they become severe.
Rationale
Correct answer: C. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
Rationale: Risk reduction focuses on early identification, prevention, teaching, and reassessment rather than unnecessary restriction or delay.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Risk reduction focuses on early identification, prevention, teaching, and reassessment rather than unnecessary restriction or delay.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.