The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?
Review the pain medications prescribed.
Monitor the client’s nonverbal behavior.
Administer PRN oral pain medication.
Ask the client what is causing the grimacing.
The Correct Answer is D
Choice A rationale
Administering PRN oral pain medication without further assessment may not be appropriate, as the client’s pain needs must be fully evaluated before intervening with medication. Pain medication should be administered based on an accurate assessment rather than solely on nonverbal cues.
Choice B rationale
Reviewing the pain medications prescribed is important, particularly if the client is exhibiting signs of uncontrolled pain. However, this intervention should be secondary to further assessment of the client’s current pain status.
Choice C rationale
Administering PRN oral pain medication without further assessment may not be appropriate, as the client’s pain needs must be fully evaluated before intervening with medication. Pain medication should be administered based on an accurate assessment rather than solely on nonverbal cues.
Choice D rationale
Asking the client what is causing the grimacing is the correct intervention to implement first. Nonverbal cues, such as grimacing, can indicate the presence of pain, even if the client denies it verbally. By closely monitoring the client’s nonverbal behavior, the nurse can gather additional information about the client’s pain experience and make appropriate interventions based on a comprehensive assessment.
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Correct Answer is D
Explanation
Choice A rationale
Wearing gloves to dispose of the needle and syringe is a good practice to prevent needlestick injuries and contamination. However, it does not directly indicate an understanding of standard precautions, which emphasize hand hygiene as a primary measure.
Choice B rationale
Removing the needle before discarding used syringes is not recommended as it increases the risk of needlestick injuries. Standard precautions emphasize the safe disposal of sharps in puncture-resistant containers without manipulating the needle.
Choice C rationale
Donning a face mask before administering medication is not a standard precaution for handling syringes and needles. Standard precautions focus more on hand hygiene and the use of gloves when there is a risk of exposure to blood or body fluids.
Choice D rationale
Washing hands before handling the needle and syringe is a fundamental aspect of standard precautions. Hand hygiene is the most effective way to prevent the transmission of infections and is a clear indication of understanding standard precautions.
Correct Answer is D
Explanation
Choice A rationale
Lubricating the thermometer before inserting it into the ear is not a standard practice for using a tympanic thermometer. Tympanic thermometers are designed to be used without lubrication, and using lubrication could interfere with the accuracy of the reading.
Choice B rationale
Holding the thermometer in place for a full three minutes is unnecessary for tympanic thermometers. These thermometers provide quick readings, usually within a few seconds, and holding it for longer does not improve accuracy.
Choice C rationale
Pulling the client’s auricle down and back is the correct technique for infants and young children. For adults, the correct technique is to pull the auricle up and back to straighten the ear canal for an accurate reading.
Choice D rationale
Using positive reinforcement to affirm that the procedure is being performed correctly is the appropriate action. The UAP is using the correct technique by pulling the client’s auricle up and back, which is the proper method for adults.