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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. Drink a mixture of warm water, whiskey, and honey at bedtime. B. Establish a regular time for going to bed and getting up. C. Ask the healthcare provider for a mild sedative for bedtime. D. Take an afternoon nap to make up for missed sleep. E. Avoid drinking caffeinated beverages late in the day.

Correct Answer is ["B","E"]

Explanation

Choice A rationale

Drinking a mixture of warm water, whiskey, and honey at bedtime is not recommended as alcohol can disrupt sleep patterns and lead to poor sleep quality.

Choice B rationale

Establishing a regular time for going to bed and getting up helps regulate the body’s internal clock and can improve sleep quality.

Choice C rationale

Asking for a mild sedative should be a last resort and only used under the guidance of a healthcare provider. Non-pharmacological methods are preferred for improving sleep

Choice D rationale

Taking an afternoon nap can interfere with nighttime sleep and is generally not recommended for those having trouble sleeping at night.

Choice E rationale

Avoiding caffeinated beverages late in the day can help improve sleep quality as caffeine is a stimulant that can interfere with falling asleep.

A. Puts on new gloves when entering a client’s room. B. Uses sterile gloves when handling body fluids. C. Keeps a pair of gloves in uniform pocket. D. Dons sterile gloves when caring for clients with HIV.

Correct Answer is A

Explanation

Choice A rationale

Puts on new gloves when entering a client’s room. This action demonstrates an understanding of standard precautions, which are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection. By putting on new gloves when entering a client’s room, the UAP is ensuring that they are not transferring any pathogens from one environment to another, thereby protecting both themselves and the client.

Choice B rationale

Uses sterile gloves when handling body fluids. While it is important to use gloves when handling body fluids, sterile gloves are not necessary unless performing a sterile procedure. Standard gloves are sufficient for most tasks involving body fluids, and the use of sterile gloves in these situations would be an unnecessary use of resources.

Choice C rationale

Keeps a pair of gloves in uniform pocket. This practice is not recommended as it can lead to contamination of the gloves. Gloves should be stored in a clean, dry place and should be taken from the box immediately before use. Keeping gloves in a pocket can expose them to contaminants, which can then be transferred to the client.

Choice D rationale

Dons sterile gloves when caring for clients with HIV. HIV is not transmitted through casual contact, and standard gloves are sufficient for routine care of clients with HIV. Sterile gloves are only necessary for sterile procedures, regardless of the client’s HIV status.

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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 ["B","E"]

Explanation

Correct Answer is A

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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An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

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Explanation

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

Correct Answer is A

Explanation

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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.