Fundamentals vitals, infection, pain Q&A

Question 1

A nurse is observing an assistive personnel (AP) obtain vital signs from an adult client. Which of the following actions by the AP requires follow up by the nurse?

Answer 1

The AP informs the client when they are counting the respirations.

According to evidence-based practice, the AP should not inform the client they are going to count their respirations. This action can lead the client to alter their breathing, which can cause inaccurate results. When obtaining vital signs, the AP should count a client’s respirations when they are relaxed and at rest.

Question 2

A nurse is preparing an in-service about vital signs for a group of newly hired assistive personnel. Which of the following information should the nurse include about measuring body temperature?

Answer 2

Oral temperature is easily accessible despite a client’s position.

One advantage of oral temperature is that it is easily accessible despite a client’s position. The oral temperature is an accurate measurement of body surface temperature but does not reflect core temperature.

Question 3

A nurse is caring for a client who has an increase in cardiac afterload. Which of the following findings should the nurse expect?

Answer 3

Increase in blood pressure

The nurse should identify that a client who has an increase in afterload increases the risk for hypertension. Afterload is the resistance of the ventricle to pump the heart muscle and eject blood into the client’s bloodstream during systole.

Question 4

A nurse is discussing the use of a client’s thigh for blood pressure measurements with an assistive personnel (AP). Which of the following information should the nurse include?

Answer 4

Use the thigh to obtain blood pressure when a client has severe edema in their arms.

The nurse should instruct the AP to obtain blood pressure measurements in the thigh when a client has severe edema in the arms or a shunt in place for dialysis.

Question 5

A nurse is evaluating the effectiveness of interventions provided to a client who has an SaO2 below the expected reference range. Which of the following manifestations requires follow up by the nurse?

Answer 5

Dyspnea

A low SaO2 indicates the body’s tissues and cells are not receiving enough oxygen and can be related to several causes including hypothermia, decreased cardiac output, or lung disease. Clients who have an SaO2 below the expected reference range of 95% to 100% can exhibit shortness of breath and difficulty breathing, or dyspnea. This indicates the interventions provided by the nurse have not been successful and require further evaluation and notification of the provider.

Question 6

A charge nurse is discussing a client’s respiratory data with a newly licensed nurse. Which of the following statements should the nurse include?

Answer 6

“Count the respiratory rate for 1 minute for clients who have a respiratory infection.”

The charge nurse should include that the nurse should count the respiratory rate for 1 min for clients who have a respiratory infection. For clients who are healthy, the nurse can count the rate for 15 seconds and multiply by 4 to determine the rate per minute.

Question 7

A charge nurse is providing an in-service for a group of nurses about cardiac output. Which of the following statements should the nurse include?

Answer 7

“Cardiac output is the amount of blood flow through the heart in 1 minute.”

The nurse should identify that cardiac output is the amount of blood pumped by the ventricles through the heart within 1 min.

Question 8

A nurse is evaluating the effectiveness of interventions used to address clients’ vital signs that were outside of the expected reference ranges. Which of the following findings indicates the intervention was effective?

Answer 8

A young adult who is experiencing an asthma attack and has a blood pressure of 116/72 mm Hg after using an inhaler

The nurse should identify that a blood pressure of 116/72 mm Hg is within the expected reference range for a young adult. The expected systolic blood pressure should be less than 120 mm Hg and the diastolic blood pressure should be less than 80 mm Hg. Therefore, the intervention of using an inhaler was effective.

Question 9

A nurse is assessing a client who has orthostatic hypotension. Which of the following actions should the nurse take?

Answer 9

Encourage the client to change positions slowly.

The nurse should identify that orthostatic hypotension is a drop in systolic pressure of at least 20 mm Hg, or a drop in diastolic pressure of at least 10 mm Hg, within 1 min of moving to a sitting or standing position after lying down.

Question 10

A nurse is caring for a client who is experiencing tachypnea due to an exacerbation of asthma. Which of the following medications should the nurse anticipate administering?

Answer 10

A bronchodilator

Tachypnea occurs during an asthma attack due to a constriction in the airways, leading to a decrease in oxygenation. The respiratory rate increases to compensate for the decrease in oxygen to the tissues. A bronchodilator decreases inflammation in the lungs, which opens the airways. This allows for improved oxygenation to the tissues, thereby decreasing the respiratory rate

Question 11

A nurse is preparing an in-service for a group of newly hired assistive personnel (AP) about body temperature. Which of the following information should the nurse include?

Answer 11

A temporal probe thermometer uses infrared scanning to determine a client’s temperature.

The nurse should instruct the AP that a temporal artery thermometer uses infrared scanning to determine the body’s core temperature. The thermometer probe is placed in the center of the forehead, swiped laterally toward the hairline, then touched to the skin behind the client’s earlobe.

Question 12

A nurse is preparing an in-service about factors affecting respiratory rate for a group of assistive personnel. Which of the following information should the nurse include?

Answer 12

Fever can increase a client’s respiratory rate.

The nurse should include that an increased body temperature can cause an increase in a client’s respiratory rate. Other factors that can increase respiratory rate include physical exertion, chronic lung disease, and anxiety.

Question 13

A nurse is discussing oxygen saturation with a client. Which of the following information should the nurse include?

Answer 13

Oxygen saturation reflects the amount of oxygen being delivered to body tissues.

Oxygen saturation is an indication of the amount of oxygen being transported to body tissues and is a direct reflection of a client’s respiratory status.

Question 14

A nurse is caring for a client who has an increase in cardiac output. Which of the following findings should the nurse expect?

Answer 14

Increase in blood pressure

The nurse should identify that an increase in cardiac output causes an increase in the client’s blood pressure. Cardiac output is the amount of blood pumped by the ventricles in 1 min.

Question 15

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A nurse is teaching a group of assistive personnel (AP) about techniques used to obtain BP. For which of the following clients should the nurse to instruct the AP to obtain an electronic BP measurement?

Answer 15

A client who has stabilized BP

measurements
Blood pressure can be obtained electronically using a machine that has a blood pressure cuff attached. The machine automatically inflates the bladder of the cuff and displays the blood pressure on a screen. This method is reserved for clients in stable condition with BP measurements within the expected reference range. Manual BP measurements are more accurate than those obtained via an electronic device, so if an abnormal reading is obtained electronically, a manual reading should be obtained.

Question 16

A nurse is reviewing the vital signs of four clients. The nurse should identify that which of the following clients has a vital sign outside of the expected reference range?

Answer 16

A 23-year-old client who runs marathons and has a blood pressure of 82/54 mm Hg

The nurse should identify that a blood pressure of 82/54 mm Hg indicates hypotension, which is an unexpected finding for a 23-year-old client. With hypotension the client will have systolic BP less than 90 mm Hg or a diastolic BP less than 60 mm Hg. The nurse should expect the client to exhibit bradycardia, or a slow heart rate, due to their high level of physical fitness. However, the nurse should gather more client data for manifestations of hypotension and report the findings to the provider.

Question 17

A nurse is evaluating the effectiveness of interventions used for clients who had alterations in vital signs. Which of the following clients’ vital signs indicate that interventions were effective? (Select all that apply.)

Answer 17

A preschooler who was exhibiting tachypnea 2 hr postoperative and now has a respiratory rate of 24/min
An older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min
A young adult who had hypotension after receiving an opioid analgesic and now has a blood pressure of 98/68 mm Hg

A preschooler who was exhibiting tachypnea 2 hr postoperative and now has a respiratory rate of 24/min is correct. The nurse should identify that a respiratory rate of 24/min for a preschooler is within the expected reference range of 20 to 25/min. This finding indicates that interventions were effective.

An older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min is correct. The nurse should identify that an apical pulse rate of 66/min is within the expected reference range of 60 to 100/min for an older adult client. This finding indicates that interventions were effective.

A young adult who had hypotension after receiving an opioid analgesic and now has a blood pressure of 98/68 mm Hg is correct. The nurse should identify that hypotension is a blood pressure of less than 90/60 mm Hg. Therefore, a blood pressure of 98/68 mm Hg indicates that the client’s blood pressure is no longer hypotensive, so interventions were effective.

A toddler who was febrile 2 hr ago due to a viral infection and has a temporal temperature of 38.2° C (100.8° F) is incorrect. The nurse should identify that a temperature of 38.2° C (100.8° F) is above the expected reference range. This finding indicates that interventions were not effective.

An adult client who had tachycardia 1 hr ago due to postoperative pain and has an apical pulse rate of 106/min is incorrect. The nurse should identify that an apical pulse rate of 106/min is above the expected reference range of 60 to 100/min for an adult client. This finding indicates interventions were not effective.

Question 18

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A nurse is caring for a client who has a heart rate of 120/min. Which of the following actions should the nurse take?

Answer 18

Instruct the client to bear down like they are having a bowel movement.

The Valsalva maneuver can be used to regulate heart rate. To elicit this, the nurse should instruct the client to “bear down” like they are having a bowel movement. This action produces a vasovagal response in the client’s body which lowers the client’s heart rate.

Question 19

A charge nurse is reviewing documentation of vital signs by a newly licensed nurse. Which of the following pieces of documentation is correct?

Answer 19

SaO2 97% right index finger, room air

The charge nurse should identify that this documentation is thorough and complete and does not require any additional information. The information provided includes the measurement, the site used, and that the client is not on oxygen.

Question 20

A nurse is planning care for a group of clients. For which of the following clients should the nurse direct an assistive personnel (AP) to obtain a rectal temperature?

Answer 20

A client who is diaphoretic and frequently chewing ice to relieve dry mouth

Oral temperatures should not be obtained in clients who have consumed food or liquids or smoked tobacco products within the previous 30 min. The client’s diaphoresis will make it difficult to obtain an accurate temperature via the tympanic membrane or temporal artery. Therefore, the nurse should direct the AP to obtain this client’s temperature rectally.

Question 21

A nurse is observing an assistive personnel (AP) who is obtaining a blood pressure reading from a client. Which of the following actions by the AP requires follow up by the nurse?

Answer 21

The AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second.

Releasing the pressure at a rate of 5 mm Hg per second is too fast. The recommended rate is 2 mm Hg per second. Releasing the valve too quickly could prevent the AP from noting the correct reading and too slowly can cause additional discomfort to the client.

Question 22

A nurse is providing teaching about thermoregulation to a group of newly licensed nurses. Which of the following statements should the nurse include in the teaching?

Answer 22

“The body lowers body temperature through sweating.”

Sweating, a natural body reaction to increased temperature, helps the body to maintain a consistent temperature by cooling the body through evaporation of the sweat from the skin, thereby lowering the body’s temperature.

Question 23

A nurse on a pediatric unit is reviewing the medical records for a group of clients. Which of the following clients has a vital sign outside the expected reference range and requires intervention?

Answer 23

A 3-year-old preschooler who has an apical pulse rate of 144/min

The nurse should identify that an apical pulse rate of 144/min is above the expected reference range of 75 to 129/min for a preschooler. This finding requires intervention by the nurse.

Question 24

A charge nurse is discussing mechanisms of loss of body heat with a newly licensed nurse. Which of the following statements should the nurse include?

Answer 24

“Radiation is the loss of body heat when a client is in close proximity to a cooler surface.”

The nurse should include that radiation is the loss of body heat that occurs when a client is in close proximity to a cooler surface. For example, radiative heat loss can occur when a client sits near a window when it is cold outside.

Question 25

A nurse is caring for a group of clients. Which of the following clients is experiencing an alteration in their respiratory rate that requires intervention?

Answer 25

A school-age child who has a respiratory rate of 14/min

The nurse should identify that a respiratory rate of 14/min is below the expected reference range of 18 to 30/min for a school-age child. The child is exhibiting bradypnea, which requires further data collection by the nurse.

Question 26

A charge nurse is reviewing the expected reference range of blood pressure in adult clients with a newly licensed nurse. Which of the following statements should the charge nurse include?

Answer 26

“Hypertension is diagnosed with two elevated measurements on two separate occasions.”

A diagnosis of hypertension is not usually made based on a single elevated measurement; there are generally at least two elevated readings taken on two or more separate occasions for the provider to determine this diagnosis.

Question 27

A nurse obtains a client’s electronic blood pressure reading of 188/96 mm Hg. Which of the following actions should the nurse take next?

Answer 27

Obtain a manual blood pressure reading from the client.

Evidence-based practice dictates that if a client’s blood pressure is not within the expected reference range when it is taken with an electronic blood pressure machine, then the nurse should recheck the blood pressure by obtaining a manual blood pressure reading to ensure accuracy.

Question 28

A nurse is caring for a client who has a heart rate of 118/min. Which of the following actions should the nurse take to improve the client’s heart rate?

Answer 28

Encourage the client to reduce intake of caffeinated soft drinks.

In an adult client, a heart rate greater than 100/min is known as tachycardia. Tachycardia can be due to exercise, anxiety, certain medications, or use of caffeine or nicotine. It can also be caused by an abnormality in the electrical system of the heart. The nurse should encourage the client to limit their intake of caffeinated soft drinks to decrease the incidence of tachycardia.

Question 29

A charge nurse in a clinic is preparing an in-service about blood pressure measurements for a group of staff members. Which of the following information should the nurse include?

Answer 29

A client who has a blood pressure of 128/86 mm Hg is considered as having stage I hypertension.

The charge nurse should include that a blood pressure of 128/86 mm Hg meets the diagnostic criteria for stage 1 hypertension. Stage I hypertension occurs when the systolic pressure is between 130 to 139 mm Hg, or the diastolic pressure is between 80 to 89 mm Hg.

Question 30

A nurse is reviewing documentation of vital signs by a newly licensed nurse for an assigned client. Which of the following entries in the chart requires follow up by the nurse?

Answer 30

Pulse rate 116/min, left radial, standing, immediately following 10 min of ambulating in hall.

This client’s pulse rate is higher than the expected reference range. While the notation of the client ambulating in the hall can be a factor in the tachycardia, the nurse does not indicate they will re-evaluate the pulse rate after the client has rested. The nurse should use clinical judgment when evaluating vital signs and wait 15 to 30 min following exercise.

Question 31

A nurse is evaluating the effectiveness of interventions provided to four clients who have unexpected findings for vital signs. Which of the following findings requires follow up?

Answer 31

A client has a radial pulse of +4 bilateral.

A peripheral pulse strength of +4 is described as bounding and is considered an unexpected finding. The nurse should check further and report the findings to the provider. A pulse strength of +2 is considered an expected finding.

Question 32

A nurse is reviewing the recent vital signs of a group of clients. Which of the following clients should the nurse see first?

Answer 32

A 52-year-old client who has an SaO2 of 92%

Using the airway, breathing, circulation approach to client care, the nurse should identify that the priority finding is the low SaO2. SaO2 is the indicator of the amount of oxygen transported to body tissues and the expected reference range is greater than 95%. Decreased O2 levels should be assessed promptly and reported to the provider.

Question 33

A nurse is planning care for a client who has hypertension. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

Answer 33

Provide the client with low-sodium meals and snacks.
Encourage the client to participate in physical activity each day.
Instruct the client in the use of relaxation techniques.
Inform the client of the importance of abstaining from using products that contain nicotine.

Question 34

A nurse is caring for a recently admitted client and as part of the plan of care, two nurses obtained simultaneous pulse rates. The client’s auscultated apical pulse was 106/min and the palpated radial pulse was 93/min. The nurse should document the findings as which of the following?

Answer 34

Pulse deficit of 13/min

A pulse deficit is the numerical difference between the apical pulse and a peripheral pulse (usually the radial) for 1 min time. This can be caused by atrial fibrillation, aortic rupture, or coronary artery disease. The nurse should document the findings in the client’s medical record and notify the provider if a pulse deficit is present.

Question 35

A nurse working on a medical-surgical unit is caring for a group of clients. Which of the following clients’ vital signs should the nurse identify is outside the expected reference range and notify the provider?

Answer 35

A client who has an apical pulse rate of 120/min

The nurse should identify the client’s apical pulse rate of 120/min is outside the expected reference range of 60 to 100/min and requires notifying the provider.

Question 36

A nurse is teaching a group of newly licensed nurses about vital sign measurements. Which of the following factors should the nurse include in the teaching?

Answer 36

Body temperature is typically lower in older adults.

The nurse should identify that body temperature is generally slightly lower in older adults than in younger adults and children.

Question 37

A nurse is preparing an in-service about peripheral pulses for a group of staff nurses. Which of the following information should the nurse include?

Answer 37

A pulse strength of +1 indicates that the pulse is weak or diminished upon palpation.

The nurse should identify that a pulse strength of +1 indicates that the pulse is weak or diminished upon palpation. This is an expected finding and requires no further evaluation.

Question 38

A nurse is discussing the physiology of blood pressure with a group of assistive personnel. Which of the following information should the nurse include?

Answer 38

Blood pressure is measured and documented in millimeters of mercury.

Blood pressure is measured in millimeters of mercury (mm Hg) and is expressed as a fraction. The pressure is measured with a sphygmomanometer.

Question 39

A charge nurse is discussing the physiology of the heart with a newly licensed nurse. Which of the following anatomical sites should the newly licensed nurse identify as the pacemaker of the heart?

Answer 39

Sinoatrial (SA) node

The SA node is the pacemaker of the heart. It consists of a small group of special cells in the right atrium which initiates electrical impulses that travel to the AV node and sets the rate of the contraction of the ventricles.

Question 40

A nurse is reviewing the vital signs for a group of clients to determine the effectiveness of interventions. Which of the following findings indicates an intervention was effective?

Answer 40

An adult client who received medication for pain 30 min ago now has a respiratory rate of 18/min.

An adult client who has a respiratory rate of 18/min is within the expected reference range of 12 to 20/min. This indicates that the administration of the pain medication was effective. Tachypnea, an increased respiratory rate, is an expected finding for clients experiencing pain, anxiety, or increased physical activity.

Question 41

A nurse is caring for a client who has hypotension. Which of the following factors should the nurse identify as a contributing factor to the client’s condition?

Answer 41

Decrease in contractility

The nurse should identify that a decrease in contractility of the client’s heart is a contributing factor to hypotension. Contractility is the ability of the heart muscle to contract effectively

Question 42

A nurse is providing care to a client who has an apical pulse rate of 54/min and is experiencing dizziness. Which of the following is the nurse’s priority action?

Answer 42

Inform the client to ask for assistance with getting out of bed.

Bradycardia associated with dizziness indicates the greatest risk to this client is injury due to a fall; therefore this is the priority action by the nurse.

Question 43

A charge nurse is evaluating a newly licensed nurse’s documentation of vital signs for several clients. Which of the following documentation should the charge nurse identify as being incomplete?

Answer 43

BP 124/82 mm Hg, lying in bed

The charge nurse should identify that this documentation is incomplete because it does not include the site from where the blood pressure was obtained.

Question 44

A nurse is evaluating the effectiveness of interventions provided to a client who was admitted for decreased circulation. Which of the following findings requires further intervention by the nurse?

Answer 44

Left radial pulse is nonpalpable

Peripheral pulses that are nonpalpable require further intervention by the nurse. The nurse should use a Doppler ultrasound stethoscope to auscultate the pulse. The nurse should also determine if the client has other manifestations of impaired circulation, such as cool, pale skin. The nurse should notify the provider of any unexpected findings.

Question 45

A nurse is assessing a 3-month-old infant during a well-child visit. Which of the following actions should the nurse take when assessing the apical pulse?

Answer 45

Place the stethoscope over the 4th intercostal space to the left of the sternum.

The nurse should auscultate the apical pulse over the apex of the heart, which is located in the 4th intercostal space to the left of the sternum in infants and children less than 7 years of age.

Question 46

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A nurse is reviewing blood flow through the heart with a group of assistive personnel. The nurse should identify that blood flows to which of the following parts of the heart as it leaves the right ventricle?

Answer 46

Pulmonary artery

As the right ventricle contracts, blood is forced into the pulmonary artery, where it enters the lungs to become oxygenated. Once oxygenated, the blood is returned to the heart via the pulmonic vein, where it enters the left atrium. It then passes through the mitral valve into the left ventricle. As the ventricle contracts, the blood is forced into the aorta and systemic circulation.

Question 47

A nurse is obtaining vital signs for a group of clients. Which of the following findings requires intervention?

Answer 47

An 11-year-old child who has a respiratory rate of 34/min

The nurse should identify that a respiratory rate of 34/min is above the expected reference range of 18 to 30/min for a school-age child. This finding requires intervention by the nurse.

Question 48

A nurse is reviewing the vital signs for a group of clients. Which of the following clients should the nurse identify as exhibiting tachycardia?

Answer 48

A young adult who has an apical pulse rate of 104/min

The nurse should identify that a pulse rate of 104/min is above the expected reference range of 60 to 100/min for a young adult. Therefore, this client is exhibiting tachycardia. The nurse should allow the client to rest in a comfortable position and recheck the apical pulse rate. If it remains elevated, the nurse should notify the provider.

Question 49

A charge nurse is teaching a group of assistive personnel (AP) about the importance of documenting accurate vital signs. Which of the following information should the charge nurse include in the teaching?

Answer 49

Recording vital signs provides critical information regarding a client’s condition.

Vital signs, including blood pressure, temperature, pulse, respiratory rate, and SaO2, reflect the client’s current health status and will vary according to changes in the client’s health condition, such as infection, stress, pain, or bleeding, and should be recorded accurately and in a timely manner.

Question 50

A nurse is preparing to obtain a young adult client’s apical pulse. In which of the following locations should the nurse place their stethoscope to auscultate the client’s pulse?

Answer 50

Apex of the heart

The nurse should identify that the apical pulse is auscultated over the apex of the client’s heart for a client who is older than 7 years of age. This is located between the 5th intercostal space to the left of the client’s sternum.

Question 51

A nurse is planning care for a group of clients and is reviewing the recent vital signs obtained by an assistive personnel. Which of the following clients should the nurse assess and recheck the vital signs prior to notifying the provider?

Answer 51

8-year-old male: respiratory rate 34/min, SaO2 97%

The nurse should recognize that this client’s respiratory rate is above the expected reference range of 20 to 25/min for a male school-age child and denotes tachypnea. While the SaO2 is within the expected reference range of greater than or equal to 95%, the nurse should assess the client, recheck the respiratory rate, and notify the provider if the child remains tachypneic.

Question 52

A charge nurse is reviewing orthostatic hypotension with a group of newly licensed nurses. Which of the following statements should the charge nurse make?

Answer 52

“A decrease of 20 millimeters of mercury in the systolic pressure with a position change indicates orthostatic hypotension.”

The charge nurse should include that a decrease of at least 20 mm Hg in the systolic pressure with a position change indicates orthostatic hypotension.

Question 53

A nurse is caring for a client who asks about factors that could cause their pulse rate to increase. Which of the following factors should the nurse include in their response?

Answer 53

Smoking

Products containing nicotine, such as cigarettes, can increase pulse rate and blood pressure.

Question 54

A nurse is reviewing the vital signs for a group of clients obtained by an assistive personnel. The nurse should identify that which of the following clients requires a follow-up assessment due to bradycardia?

Answer 54

A young adult who has a radial pulse rate of 56/min

The nurse should identify that a young adult client who has a radial pulse rate of 56/min is exhibiting bradycardia. The nurse should confirm the pulse rate by auscultating the apical pulse for 1 min, as well as assessing the client for manifestations of bradycardia such as fatigue, dizziness, or shortness of breath.

Question 55

A nurse is planning care for a client who is experiencing tachycardia. Which of the following interventions should the nurse plan to include?

Answer 55

Encourage the client to practice relaxation techniques each day.

Tachycardia can be caused by stress or anxiety. The nurse should encourage the client to participate in relaxation techniques such as guided imagery, meditation, or yoga, because these can decrease heart rate and blood pressure.

Question 56

A nurse is planning care for a group of clients and is delegating to the assistive personnel (AP) to take the clients’ vital signs. For which of the following clients should the nurse obtain the vital signs rather than the AP?

Answer 56

A client who was recently admitted and reports chest pain

The nurse should identify that a new onset of chest pain is an acute change in condition. The nurse should not delegate this task to the AP. Once the client is stable, the nurse can delegate subsequent measurement of vital signs to an AP.

Question 57

A nurse is reviewing the vital signs obtained by an assistive personnel at 1200. For which of the following clients should the nurse plan to intervene?

Answer 57

Toddler who has a respiratory rate of 44/min

The expected reference range for respiratory rate in toddlers is 25 to 30/min, so this client will need to be assessed by the nurse, as they are exhibiting tachypnea. The nurse should reassess the vital signs to ensure previous readings were accurate and evaluate the client to determine a potential cause for the increased respiratory rate, such as anxiety, crying, or physical exertion.

Question 58

A nurse is assisting with implementing an infection control bundle for clients at risk for catheter-associated urinary tract infections (CAUTIs). Which of the following interventions should the nurse include in the bundle?

Answer 58

Try to use alternatives before inserting indwelling urinary catheters.

The nurse should include in the bundle to try to use other methods of urine collection before inserting an indwelling urinary catheter, such as a condom catheter, to reduce the risk for CAUTI.

Question 59

A nurse is performing a throat culture on a client. Which of the following actions should the nurse take?

Answer 59

Swab the back of the client’s pharyngeal wall.

The nurse should swab the client’s tonsils, the tonsillar pillars, or the back of the pharyngeal wall, to obtain an accurate culture. The nurse should avoid touching any other areas of the client’s mouth or pharynx because this can interfere with the test results.

Question 60

A nurse is assisting in providing an in-service about infectious agents to a group of nurses. The nurse should include in the teaching that tuberculosis is transmitted by which of the following modes of transmission?

Answer 60

Airborne

The nurse should include in the teaching that tuberculosis is transmitted through the airborne mode of transmission. Clients who have tuberculosis should be placed in a negative pressure, private room. The door to the client’s room should remain closed, and the nurse should wear an N95 mask when providing care to the client.

Question 61

A nurse is assisting with teaching a newly licensed nurse about laboratory tests that can indicate generalized inflammation. The nurse should include which of the following laboratory tests?

Answer 61

C-reactive protein

C-reactive protein is a nonspecific marker that can increase when inflammation is present.

Question 62

A nurse is assisting with teaching about personal protective equipment with a newly licensed nurse. Which of the following instructions should the nurse include?

Answer 62

Gloves should be removed from the inside out.

The nurse should instruct to remove gloves from the inside out to reduce the risk of transmission of infectious agents.

Question 63

A nurse is supervising a newly licensed nurse perform hand hygiene. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

Answer 63

Turns off the faucet with a towel

The nurse should use a towel to turn off the faucet to reduce the risk of contaminating the hands.

Question 64

A nurse is planning to admit a client who has respiratory syncytial virus (RSV). Which of the following transmission-based precautions should the nurse plan to implement?

Answer 64

Contact

Contact precautions are transmission-based precautions that are used when caring for a client who has RSV.

Question 65

A nurse is caring for a client who is on contact precautions. Which of the following actions should the nurse take?

Answer 65

Place the client in a private room.

The nurse should place the client in a private room to reduce the risk of transmitting the infectious agent to others.

Question 66

A nurse is setting up a sterile field to perform a dressing change on a client. Which of the following actions should the nurse take?

Answer 66

Open the first flap on the sterile package away from their body.

The nurse should open the first flap on a sterile package away from their body to reduce the risk for contamination.

Question 67

A nurse is assisting with teaching a newly licensed nurse about infection control. The nurse should include in the teaching that which of the following types of precautions requires the use of an N95 mask?

Answer 67

Airborne

Airborne precautions are used to prevent transmission of infections caused by small droplets in the air, such as measles or chickenpox. A nurse who is caring for a client on airborne precautions should don an N95 mask or a high-level respirator when entering the room.

Question 68

A nurse is assisting with teaching a group of nurses on processes that can trigger an inflammatory response in the body. The nurse should include that which of the following is an infectious trigger?

Answer 68

Bacteria

Bacteria is an infectious trigger to an inflammatory response. The inflammatory response is the natural defense of the body to a foreign substance, an infectious agent, or an irritation.

Question 69

A nurse is assisting with teaching a newly licensed nurse about needlestick injuries. Which of the following instructions should the nurse include?

Answer 69

Report needlestick injuries to the nursing supervisor.

The nurse should report all needlestick injuries with a contaminated needle immediately to the supervisor and complete paperwork as designated by the healthcare organization.

Question 70

A nurse is assisting with teaching a newly licensed nurse about removing personal protective equipment (PPE). Which of the following items should the nurse instruct to remove first?

Answer 70

Gloves

According to evidence-based practice, the nurse should first remove the gloves, to reduce the risk of transmitting an infectious agent.

Question 71

A nurse is assisting with teaching a newly licensed nurse about infectious agents. The nurse should include in the teaching that pertussis is transmitted by which of the following modes of transmission?

Answer 71

Droplet

The nurse should include in the teaching that pertussis is transmitted through large droplets in the air from coughing or sneezing. The client should be placed in a private room. The nurse should wear a surgical mask when providing care for clients who are on droplet precautions.

Question 72

A nurse is assisting with teaching a newly licensed nurse about airborne infection isolation rooms (AIIR). Which of the following information should the nurse include?

Answer 72

The door to the AIIR should remain closed.

The nurse should instruct to keep the door to the AIIR closed at all times to reduce the risk of transmission of the infectious agent.

Question 73

A nurse is performing hand hygiene after caring for a client who has Clostridium difficile. Which of the following hand hygiene methods should the nurse use?

Answer 73

Soap and water

The nurse should wash their hands with soap and water after caring for a client who has an infection caused by spores, such as Clostridium difficile.

Question 74

A nurse is caring for a client who has acquired an infection from a visitor. The client is an example of which of the following links in the chain of infection?

Answer 74

Susceptible host

The susceptible host is the client who acquired the infection. The susceptible host becomes a reservoir for the infectious agent.

Question 75

A nurse is assisting with teaching a newly licensed nurse about surgical asepsis. Which of the following statements should the nurse make?

Answer 75

“Remove nail polish on your fingernails if it is chipped.”

Nail polish, if worn, should not be chipped, because the chipped areas can harbor bacteria.

Question 76

A nurse is caring for a client who has influenza. The client asks how they acquired the infectious agent. The nurse should inform the client that influenza is transmitted by which of the following modes?

Answer 76

Droplet

The nurse should inform the client that influenza is transmitted through large droplets in the air. The client should be placed in a private room, and the nurse should wear a surgical mask when caring for the client.

Question 77

A nurse is wearing gloves while caring for a client. In which of the following situations should the nurse obtain a new pair of gloves?

Answer 77

After changing a dressing on the client and before documenting findings on a computer

The nurse should change the gloves to avoid contamination from the client to the keyboard or computer, and in between clients.

Question 78

A nurse is caring for a client who acquired an infection after touching a faucet that an infected person had touched. Which of the following links in the chain of infection does the faucet represent?

Answer 78

Reservoir

The faucet is an example of a reservoir in the chain of infection. The reservoir is the location where the infectious agent lives, grows, reproduces itself, and waits to be transmitted to a susceptible host.

Question 79

A nurse in a clinic is caring for a client who reports generalized aches and fever for the past 12 hr. The nurse suspects the client has acquired an infection. Which of the following stages of infection is the client likely experiencing?

Answer 79

Prodromal

The prodromal stage is the second stage of infection. In this stage, the client begins having vague, nonspecific manifestations, such as fever, chills, headache, and malaise, as the infectious agent replicates.

Question 80

A nurse is caring for a client who states, “I am feeling so much better. My fever is gone, and I have a good appetite.” The nurse should identify the client is likely in which of the following stages of infection?

Answer 80

Convalescence

The convalescent stage is the last stage of infection in which the client returns to a previous or a new, stabilized state of health.

Question 81

A nurse is assisting with teaching a newly licensed nurse about hand hygiene for surgical asepsis. Which of the following instructions should the nurse include?

Answer 81

Apply chlorhexidine and ethanol to the hands.

The nurse should instruct the newly licensed nurse to apply chlorhexidine and ethanol solution to their hands to remove pathogens when using surgical asepsis.

Question 82

A nurse is admitting a client who has vancomycin-resistant enterococcus (VRE) of the urine. The nurse should place the client on which of the following precautions?

Answer 82

Contact

Contact precautions reduce the risk of transmitting infectious agents, such as VRE, through direct or indirect contact. The nurse should wear a gown and gloves when caring for the client.

Question 83

A nurse is evaluating a client’s pain level using the PQRST mnemonic. Which of the following questions should the nurse ask to evaluate the letter “R”?

Answer 83

Can you point to where you are having your pain?”

The nurse should use the PQRST mnemonic to obtain more information about the client’s pain. This question evaluates the region of the client’s pain.

Question 84

A nurse is caring for a client who reports muscle pain to the lower back that has persisted for over a year after a motor-vehicle crash. In which way should the nurse categorize this client’s pain?

Answer 84

Chronic pain

Chronic pain is pain that has been present usually for 3 to 6 months or longer after the injury or damage has healed. Examples of chronic pain are arthritis pain or pain from a back injury. Chronic pain can physically and emotionally debilitate a client.

Question 85

A nurse is caring for an older adult client who has a cognitive impairment and is postoperative. Which of the following actions should the nurse take?

Answer 85

Evaluate the client for pain by observing their behavior.

Clients who have cognitive impairment might be unable to appropriately report their pain. The nurse should observe for behaviors that suggest pain is present such as guarding, grimacing, restlessness, and other behavioral changes.

Question 86

A charge nurse is reviewing factors that can affect a client’s perception of pain with a newly licensed nurse. Which of the following should the charge nurse include? (Select all that apply.)

Answer 86

Stress is correct. Stress levels are psychological factors that can affect a client’s experience with pain. Other psychological factors include mood/affect, catastrophizing (assuming the worst), and coping.

Dietary practices is incorrect. Factors that can affect a client’s experience with pain include biological, psychological, and social factors. Dietary practices do not affect pain perception.

Culture is correct. A client’s identified culture is a social factor that can affect a client’s experience with pain. Social factors also include economic factors, the social environment, and social support.

Social support is correct. The availability of support from family and or friends is a social factor that can affect a client’s experience of pain. Social factors also include cultural and economic factors and the social environment.

Disease severity is correct. The severity of a client’s disease is a biological factor that can affect a client’s experience of pain. Biological factors also include nociception, inflammation, and brain function.

Question 87

A nurse is caring for a client who has severe pain and repeatedly asks for pain medication. The nurse is busy and forgets to assess the client’s pain and administer prescribed pain medication. Which of the following can the nurse be charged with?

Answer 87

Negligence

Negligence means failure to perform in a manner that a reasonable person would have. By failing to assess the client’s pain and administer the client’s pain medication, the nurse was negligent.

Question 88

A nurse is caring for a client who has a prescription for oxycodone 5 to 10 mg PO every 4 to 6 hr as needed for pain rating 7 to 10 on a 0 to 10 scale. Fifteen minutes after receiving the dose, the client reports to the nurse their pain is still a 7 and has not changed. Which of the following actions should the nurse take?

Answer 88

Offer to assist the client with nonpharmacological relief strategies.

The oxycodone would not have had time to peak and to be effective after 15 min. The nurse should offer to assist the client with nonpharmacological pain relief strategies until the medication has had time to work. Oral oxycodone peak effects should be noted 60 to 90 min after administration.

Question 89

A nurse is assessing a client who is nonverbal for the presence of pain. Which of the following findings indicate an increased level of discomfort? (Select all that apply.)

Answer 89

Grimacing is correct. Clients who have cognitive impairment or communication challenges (e.g., expressive aphasia) require careful nursing assessment. The client might not report pain effectively, and the nurse should look for behaviors that suggest pain is present such as guarding, grimacing, restlessness, and other behavioral changes.

Restlessness is correct. Clients who have cognitive impairment or communication challenges (e.g., expressive aphasia) require careful nursing assessment. The client might not report pain effectively, and the nurse should look for behaviors that suggest pain is present such as guarding, grimacing, restlessness, and other behavioral changes.

Elevated temperature is incorrect. An elevated temperature is not an indication of an increased pain level. Physiologic indicators of pain include changes to vital signs such as an elevated blood pressure or pulse.

Increased diaphoresis is correct. Objective indicators of pain include crying, sweating, restlessness, grimacing, or guarding by the client. Objective indicators are manifestations that can be observed by the nurse using their senses of sight, hearing, smell, and touch.

Bradycardia is incorrect. Bradycardia is not an indication of an increased pain level. An increase in the resting heart rate of greater than 20/min can be a physiologic indicator of the presence of pain.

Question 90

A nurse is caring for a client who has a prescription for hydromorphone 1 to 2 mg IM every 4 hr as needed for a pain rating of 4 to 6 on a 0 to 10 scale. The client has never taken hydromorphone before. Which of the following actions should the nurse plan to take?

Answer 90

Administer 1 mg IM.

When a client has a prescription that includes a range, and the client has never taken the medication previously, the nurse should administer the lowest dose to the client. If the dose is ineffective, the nurse can increase the dosage up to the maximum amount in the range prescribed by the provider.

Question 91

A nurse is caring for a client who has kidney stones. Which of the following manifestations is an objective indicator of pain?

Answer 91

The client is diaphoretic.

The nurse should identify that sweating is an objective manifestation of pain. Objective data is information the nurse can gather by using their five senses. Sweating can be visually noticed by the nurse.

Question 92

A nurse is caring for a group of clients on the pediatric unit. For which of the following clients should the nurse use the FLACC Pain Scale to determine their pain level? (Select all that apply.)

Answer 92

A 12-year-old client who has had an appendectomy is incorrect. A 12 year old would be able to cognitively report their pain level using a Numeric Rating Scale (NRS) or a Visual Analog Scale (VAS). The FLACC Pain Scale is recommended for children from 2 months to 7 years and for cognitively disabled children.

A 3-year-old toddler who has a fractured femur is correct. The FLACC Pain Scale is recommended for children from 2 months to 7 years. A 3 year old might not be able to accurately report their pain using a NRS or VAS due to their cognitive development at this age.

A 6-day-old infant who had a surgical repair of a heart defect is incorrect. The FLACC Pain Scale is recommended for children from 2 months to 7 years and for cognitively disabled children. The Crying, Requires Oxygen, Increased Vital Signs, Expression, Sleeplessness (CRIES) Scale is more appropriate for the age of this client.

A 14-year-old client who has severe cognitive and developmental delays is correct. Even though this client is of an age greater that than the ages recommended for use of the FLACC, this client has cognitive and developmental delays and might not be able to appropriately rate their pain using a NRS or VAS. The FLACC Pain Scale is recommended for children who are cognitively disabled.

A 5-year-old preschooler who is experiencing pain during a sickle cell crisis is correct. A 5-year-old child might not be able to accurately report their level of pain using other pain scales. The FLACC Pain Scale is recommended for children from 2 months to 7 years.

Question 93

A nurse is assisting with a staff in-service regarding pain control. Which of the following statements by a staff member indicates an understanding of the information? (Select all that apply.)

Answer 93

“A client’s religious beliefs might affect the way they respond to pain” is correct. The nurse should be aware of factors that could inhibit communication with the client and prevent pain control, such as differences in ethnic backgrounds or religious beliefs.

“Herbal therapies are not permitted for a client receiving prescription pain medication” is incorrect. If a client chooses to use herbal medications, the nurse should advocate for the client to be able to continue using them. The nurse should consult with the provider and pharmacist to ensure there are no interactions or special precautions needed in order to protect the client.

“The client’s past pain experiences are related to their current pain and pain management” is correct. The client’s past pain experiences are related to their current pain and pain management.

“If a client can rate their pain using a numeric pain scale, there is no need to note nonverbal findings” is incorrect. The nurse should document client verbalizations regarding pain and any physical findings as part of a complete pain assessment.

“Pain control might be harder to achieve if the nurse and client speak different primary languages” is correct. The nurse should be aware of factors that could inhibit communication with the client and prevent pain control, such as language barriers or educational differences.

Question 94

A nurse is reviewing a new prescription with a client who reports difficulty managing their chronic pain. Which of the following statements should the nurse include?

Answer 94

“You should write down the pain interventions you use and your pain rating before and after.”

Keeping a pain diary or a pain log can be helpful for the client to determine if medications or treatments are helping over time.

Question 95

A nurse is discussing end-of-life pain management with a group of coworkers. Which of the following should the nurse include as barriers to end-of life pain management? (Select all that apply.)

Answer 95

Fear of addiction is correct. Barriers to end-of-life pain management from a client or their family include fear of addiction. This leads to pain being undertreated or not treated at all. Every client has the right to effective pain management as they near the end of life.

Belief that pain is an expected part of their illness is correct. Barriers to end-of-life pain management from a client or their family include the belief that pain is an expected part of their illness. This leads to pain being undertreated or not treated at all. Every client has the right to effective pain management as they near the end of life.

Inability to sleep is incorrect. The inability to sleep is not a barrier to end-of-life pain management. The inability to sleep might be due to pain or other physical or psychosocial issues, and the nurse should determine what factors are contributing to the client’s inability to sleep.

Lack of support is incorrect. Lack of support is not a barrier to end-of-life pain management. The nurse should consider this factor while planning effective end-of-life pain management for this client.

Inadequate pain assessment is correct. The client’s pain assessment can be inadequate due to several factors, such as the client’s denial of pain, the client being unable to verbally express their level of pain due to unconsciousness or aphasia, or the client’s or nurse’s fear of causing adverse effects from the prescribed medications.

Question 96

A nurse is discussing the use of heat therapy with a newly licensed nurse. The nurse should include that heat therapy is effective for which of the following conditions? (Select all that apply.)

Answer 96

Muscular pain is correct. The nurse should discuss the fact that heat therapy, in the form of a heating pad or hot water bottle, is typically used for muscular pain relief, such as back pain or menstrual pain.

Active bleeding is incorrect. Active bleeding is not a condition where heat therapy is effective. It is contraindicated for active bleeding because heat causes vasodilation and increases bleeding.

Backache is correct. The nurse should discuss the fact that heat therapy, in the form of a heating pad or hot water bottle, is typically used for muscular pain relief, such as back pain or menstrual pain.

Menstrual discomfort is correct. The nurse should discuss the fact that heat therapy, in the form of a heating pad or hot water bottle, is typically used for muscular pain relief, such as back pain or menstrual pain.

Swollen extremity is incorrect. The use of heat is contraindicated for a swollen extremity. The nurse should apply an ice pack to decrease swelling

Question 97

A nurse is providing end-of-life care for a client who is unresponsive and near death. The client’s family asks the nurse about managing the client’s pain. Which of the following statements should the nurse make to the client’s family?

Answer 97

“Your family member has the right to receive effective pain management.”

According to the American Society for Pain Management Nursing and the Hospice and Palliative Nurses Association position statement, end-of-life effective pain management is a basic human right. Clients who are receiving end-of-life care should receive special consideration for pain management.

Question 98

A nurse is reviewing information for several clients on the unit. The nurse should recognize that which of the following clients is at greatest risk for respiratory depression?

Answer 98

A client who had surgery 3 hr ago and is receiving IV hydromorphone PRN

Use of an opioid medication can decrease the respiratory rate, and the first 4 hr postoperative are when the client is at highest risk for surgical complications. Therefore, the nurse should identify that the client who had surgery 3 hr ago and is receiving IV hydromorphone is at greatest risk for respiratory depression.

Question 99

A nurse is discussing the FLACC scale with a newly licensed nurse. Which of the following categories should the nurse include? (Select all that apply.)

Answer 99

Face is correct. Face is one of the categories included in the FLACC pain assessment. The nurse should observe the client’s facial expression and determine a score.

Legs is correct. Legs is one of the categories included in the FLACC pain assessment. The nurse should observe the client’s position, tone, and extremities and determine a score.

Alert is incorrect. Alert is not a category included in the FLACC pain assessment. Activity is one of the categories included in the FLACC pain assessment. The nurse should observe the client’s activity level and determine a score.

Circulation is incorrect. Circulation is not a category included in the FLACC pain assessment. Cry is one of the categories included in the FLACC pain assessment. The nurse should observe the client to determine if they are crying and assign a score.

Consolability is correct. Consolability is a category included in the FLACC pain assessment. The nurse should observe the client to determine if they are consolable and assign a score.

Question 100

A nurse is evaluating a group of clients who are experiencing pain. Which of the following clients should the nurse identify as experiencing neuropathic pain?

Answer 100

A client who has diabetes mellitus and reports bilateral burning foot pain without signs of injury

Neuropathic pain is often referred to as nerve pain and arises from the somatosensory system. Neuropathic pain includes diabetic neuropathy, phantom limb pain, and pain associated with a spinal cord injury. Neuropathic pain is frequently described as intense, shooting, or burning.

Question 101

A nurse is reviewing discharge instructions for a client who has a prescription for morphine oral solution 10 to 20 mg every 4 hr PRN. Which of the following statements by the client indicates an understanding of the instructions?

Answer 101

“I will keep the morphine bottle in a locked cabinet in my kitchen.”

Morphine is a medication that carries significant risks to others, including children, and should only be accessible and used by the client for whom it is prescribed. Storing the medication in a high cabinet prevents accidental access to the morphine by others.

Question 102

A nurse is discussing cutaneous stimulation with a client who has back pain. Which of the following methods should the nurse include? (Select all that apply.)

Answer 102

Transcutaneous electronic stimulating unit (TENS unit) is correct. The nurse should include transcutaneous electronic stimulating unit (TENS unit) as a method of cutaneous stimulation. This nonpharmacological cutaneous stimulation can be effective for the relief of back pain.

Distraction techniques is incorrect. Distraction techniques are a nonpharmacological pain intervention that use cognitive strategies such as relaxation, imagery, mindfulness, meditation, and music therapy. These strategies do not involve stimulation of the skin nor the need to touch the client. Cognitive strategies have been effective in the treatment of acute and chronic pain.

Massage is correct. The nurse should include massage as a method of cutaneous stimulation. This nonpharmacological cutaneous stimulation can be effective for the relief of back pain.

Acupuncture is correct. The nurse should include acupuncture as a method of cutaneous stimulation. This nonpharmacological cutaneous stimulation can be effective for the relief of back pain.

Cold therapy is correct. The nurse should include the application of cold therapy as a method of cutaneous stimulation. This nonpharmacological cutaneous stimulation can be effective for the relief of back pain.

Question 103

A nurse is monitoring a client who is 2 hr postoperative and is receiving morphine via PCA pump. Which of the following findings should the nurse plan to monitor to detect opioid-induced ventilatory impairment (OIVI)? (Select all that apply.)

Answer 103

Bowel sounds is incorrect. While opioid medications can affect bowel sounds, bowel sounds do not provide information about OIVI.

Deep tendon reflexes is incorrect. Deep tendon reflexes are an indicator of neurologic function and do not provide information about OIVI.

Respiratory rate is correct. The nurse should plan to monitor the respiratory rate frequently. A finding below the expected reference range could indicate OIVI.

Capnography is correct. The nurse should recognize that capnography (measuring carbon dioxide) can assist with identifying OIVI.

Oxygen saturation is correct. The nurse should plan to monitor the client’s oxygen saturation frequently or continuously, depending on policy. A finding below the expected reference range could indicate OIVI.

Question 104

A nurse is caring for a client who has a prescription for heat therapy for knee pain. The nurse should apply heat therapy to the client’s knee for how long?

Answer 104

20 min

The nurse should apply heat therapy for no more 20 min at a time with at least a 20-min break after usage.

Question 105

A nurse is caring for a client who is postoperative following abdominal surgery and has a morphine PCA pump. Which of the following medications should the nurse ensure is available in case the client develops respiratory depression?

Answer 105

Naloxone

Naloxone is a reversal agent for respiratory depression caused by opioids. It works quickly to reverse the effects of opioids on the client’s respiratory system.

Question 106

A nurse is teaching staff about the ethical principle of justice and how it relates to pain management for clients. Which of the following statements should the nurse make?

Answer 106

“Justice allows the client the opportunity to be treated fairly.”

Justice requires that all clients be treated fairly in regard to their pain management regardless of age, ethnicity, or history, such as substance use disorder or limited social and economic resources. Pain relief should be available to all clients.

Question 107

A nurse is discussing transcutaneous electrical nerve stimulation (TENS) treatment with a client who has chronic lower back pain. Which of the following statements should the nurse include? (Select all that apply.)

Answer 107

“You can be taught how to use TENS therapy at home” is correct. TENS therapy can be provided by the nurse or the client can be taught to use the TENS unit and self-administer in the home setting.

“We will insert very small sterile needles into your skin to block your pain” is incorrect. This statement describes the procedure used for acupuncture. TENS therapy is a noninvasive therapy and uses electrodes applied to the skin to deliver the low-voltage electrical impulses.

“This therapy may result in you having some temporary bruising at the site of application” is incorrect. Localized bruising, swelling, pain, or numbness to the area of application are adverse effects of extracorporeal shock-wave lithotripsy (ESWL). No adverse effects of TENS are expected. The skin electrodes used to deliver the low-voltage impulses can produce an allergic reaction in some clients.

“The TENS therapy delivers low-voltage electrical impulses to the skin over the painful areas” is correct. These low-voltage electrical impulses reduce the nervous system’s ability to transmit pain from the area of application to the brain. In addition, these impulses stimulate the body to produce endorphins, which also assist in relieving pain.

“We will adjust the intensity, pulse rate, and duration of the electrical pulses during your therapy” is correct. The intensity, pulse rate, and duration of each pulse of treatment with TENS therapy can be adjusted by the nurse or the client.

Question 108

A nurse is reviewing the plan of care for several clients who are receiving treatment for pain. Which of the following actions should the nurse plan to take to evaluate the clients’ pain control? (Select all that apply.)

Answer 108

Consider each client’s cultural preferences is correct. The nurse must consider client factors that can affect their perception, response to, and report of pain, such as culture and socioeconomic status.

Determine the effectiveness of nonpharmacological strategies is correct. The nurse should evaluate the effectiveness of each individual pain strategy, including both pharmacological and nonpharmacological. This helps determine which strategies are ineffective so that more effective strategies can be used consistently.

Record the clients’ subjective reports rather than the nurse’s objective observations is incorrect. The nurse should document both observed or measured information as well as client-reported information regarding the client’s pain in the medical record.

Recognize that older adult clients over-report their pain level is incorrect. The nurse should identify that older adult clients tend to underreport pain. The nurse should encourage clients to report their pain and use a variety of measures to determine the clients’ level of comfort.

Use a pain scale specific to each client’s cognitive abilities is correct. The nurse should ensure that the pain scale used to measure a client’s pain level is appropriate to their abilities, whether performing an initial pain assessment or evaluating pain effectiveness.

Question 109

A nurse is planning to teach coworkers about the legal and ethical principles used with pain management. Which of the following examples should the nurse include as an example of autonomy?

Answer 109

A nurse provides a client with the opportunity to take an intramuscular injection or oral medication for pain relief.

This is an example of autonomy. The nurse is providing the client their right of self-determination by permitting the client an ability to make an informed decision.