PROCTORED) 2025 QUESTIONS & ANS..
1 of
15
Term
The nurse is caring for a postoperative client recovering from a
medial meniscus repair of the right knee. Which action should the nurse
take to assist with pain management?
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,First (primary) intention
A wound with minimal tissue loss, such as a surgical incision, heals
by closure, which is first, or primary, intention. Wounds that are
not closed heal by either second (secondary) or third (tertiary)
intention.
The incision appears both swollen and bluish in color.
A hematoma is a localized collection of blood underneath the tissues.
It appears as swelling, change in color, sensation, or warmth or a mass
that often takes on a bluish discoloration. A hematoma near a major
artery or vein is dangerous because it can put pressure on the vein
or artery and obstruct blood flow.
Itching is not a complication. Incisions should be approximated with edges
together; this is a sign of normal healing. After surgery, when nerves
in the skin and tissues have been traumatized by the surgical
procedure, it is expected that the client will experience pain.
Place moist sterile gauze over the
site. Place the client supine.
Contact the surgical team.
The presence of an evisceration (protrusion of visceral organs through a
wound opening) is a surgical emergency. Immediately place the client
supine, place
damp sterile gauze over the site, contact the surgical team, do not allow
the
client anything by mouth (NPO), observe for signs and symptoms of
shock, and prepare the client for emergency surgery.
Apply ice.
Ice assists in preventing edema formation, controlling bleeding, and
anesthetizing the body part. Elevation (not dependent) assists in
preventing edema, which in turn can cause pain. Monitoring vital
signs every 15
minutes is routine postoperative care and includes a pain
assessment but in itself is not an intervention that decreases pain.
Checking the pulses is
important to monitor the circulation of the extremity but in itself is
, not a pain management intervention.