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The nurse is reviewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client’s plan of care? Select all that apply.

Determine client’s subjective measure of pain using a numerical pain scale.

Implement a 24-hour schedule of routine administration of prescribed analgesic.

Assist the client to ambulate as much as possible during waking hours.

Provide comfort measures such as topical warm application and tactile massage.

Encourage increased fluid intake and measure urinary output every 8 hours.

Question Solution

Correct Answer : A,B,D

Choice A rationale

Determine client’s subjective measure of pain using a numerical pain scale. Assessing the client’s pain using a numerical pain scale allows the nurse to understand the client’s perception of their pain and to monitor changes over time. This is a crucial step in managing chronic pain as it provides a baseline for evaluating the effectiveness of interventions.

Choice B rationale

Implement a 24-hour schedule of routine administration of prescribed analgesic. Chronic pain management often requires a consistent and routine administration of analgesics to maintain a stable level of pain control. This approach helps to prevent the peaks and troughs of pain that can occur with as-needed dosing.

Choice C rationale

Assist the client to ambulate as much as possible during waking hours. While ambulation can be beneficial for some clients, it may not be appropriate for all clients with chronic pain, especially if the pain is severe or if ambulation exacerbates the pain. Therefore, this intervention should be individualized based on the client’s condition.

Choice D rationale

Provide comfort measures such as topical warm application and tactile massage. Non- pharmacological interventions such as warm applications and massage can help to alleviate pain and improve comfort. These measures can be used in conjunction with pharmacological treatments to provide a more comprehensive approach to pain management.

Choice E rationale

Encourage increased fluid intake and measure urinary output every 8 hours. While maintaining adequate hydration is important, this intervention is not directly related to the management of chronic pain. It may be more relevant for clients with other conditions such as renal issues.

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A. I’m sorry, but your child’s medical information is none of your business. B. I can give you those results as soon as I get them back from the laboratory. C. I can only give medical information to your child because they are legally an adult. D. The healthcare provider will share this information with you.

Correct Answer is C

Explanation

Choice A rationale

Telling the parents that their child’s medical information is none of their business is not appropriate. It is important to communicate respectfully and explain the legal status of the emancipated minor.

Choice B rationale

Promising to give the results to the parents as soon as they are back from the laboratory is not appropriate. The nurse should respect the legal status of the emancipated minor and their right to privacy.

Choice C rationale

Informing the parents that the nurse can only give medical information to their child because they are legally an adult is the best response. This explains the legal status of the emancipated minor and respects their autonomy.

Choice D rationale

Telling the parents that the healthcare provider will share the information with them is not appropriate. The nurse should respect the legal status of the emancipated minor and their right to privacy.

A. Monitor the client’s white blood cell count. B. Send wound drainage for culture and sensitivity. C. Institute contact precautions for staff and visitors. D. Explain the purpose of a low bacteria diet. E. Use standard precautions and wear a mask.

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Monitoring the client’s white blood cell count is essential to assess the presence and severity of infection. An elevated white blood cell count can indicate an ongoing infection, including MRSA.

Choice B rationale

Sending wound drainage for culture and sensitivity is crucial to identify the specific bacteria causing the infection and to determine the most effective antibiotics for treatment.

Choice C rationale

Instituting contact precautions for staff and visitors is necessary to prevent the spread of MRSA. This includes wearing gloves and gowns when entering the client’s room and ensuring proper hand hygiene.

Choice D rationale

Explaining the purpose of a low bacteria diet is not relevant to the management of MRSA infections. MRSA management focuses on infection control measures and appropriate antibiotic therapy.

Choice E rationale

Using standard precautions and wearing a mask is not specific to MRSA management. While standard precautions are always important, contact precautions are more relevant for preventing the spread of MRSA.

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The nurse is reviewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client’s plan of care? Select all that apply.

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Correct Answer is C

Explanation

Correct Answer is ["A","B","C"]

Explanation

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Take full exam for free The nurse is reviewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client’s plan of care? Select all that apply.

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A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client’s parents arrive and are asking querry about the client’s laboratory results. Which response is best for the nurse to provide?

Correct Answer is C

Explanation

A client who is paraplegic is admitted with a foul-smelling drainage from a sacral ulcer.The client is suspected to have a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL vial. Which action should the nurse perform with the remainder of the medication?

A client with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage?

The nurse assesses an older adult client’s ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client’s posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?

The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

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The nurse is teaching a client about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

When providing health teaching to older adult clients, which action is most important for the nurse to implement?

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The nurse is reviewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client’s plan of care? Select all that apply.