Nokea
A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to
- A. have the client identify coping methods
- B. get the description of the location and intensity of the pain
- C. accept the client's report of pain
- D. determine the client's status of pain
Correct Answer: C
Rationale: accept the client's report of pain. Although all of the options above are correct, the first and most important piece of information in this client's pain assessment is what the client is telling you about the pain -- 'the client's report.'
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The nurse observes that the NA enters the client room, provides direct care, and then exits without performing any hand hygiene. Which is the appropriate initial action of the nurse?
- A. Inform the nurse manager about the NA's performance.
- B. File a facility incident or variance report immediately.
- C. Talk to the NA immediately about performing hand hygiene.
- D. Tell the client to remind all staff to perform hand hygiene.
Correct Answer: C
Rationale: C: Immediate discussion with the NA addresses the issue directly and promotes compliance. A, B: These are secondary actions. D: Client involvement is inappropriate.
When caring for a client with a post-right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote
- A. relaxation and sleep
- B. deep breathing and coughing
- C. incisional healing
- D. range of motion exercises
Correct Answer: B
Rationale: The priority is preventing postoperative respiratory complications. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. Client compliance with recommended deep breathing and coughing exercises will only be achieved with the appropriate pain management.
The infection control nurse receives hospital laboratory confirmation that the client has positive sputum cultures for mycobacterium tuberculosis. Which action should be taken by the nurse?
- A. Prepare a statement for the hospital spokesperson to release to the news agencies
- B. Recommend that only staff with recent negative tuberculin skin tests provide care
- C. Implement measures to notify the local or state health department about the case
- D. Notify the nearest infectious disease facility and prepare the client for transfer
Correct Answer: C
Rationale: C: TB is a reportable disease, requiring health department notification. A: Media release is inappropriate. B: All staff can provide care with precautions. D: Transfer is unnecessary.
The HCP documents that the client has a generalized infection. Which specific assessment finding should the nurse expect?
- A. Redness and warmth at the site
- B. Swelling and pain at the site
- C. Hypertension and bradycardia
- D. Fever and widespread muscle aches
Correct Answer: D
Rationale: D: Generalized infections cause systemic symptoms like fever and muscle aches. A, B: These are localized signs. C: Hypotension and tachycardia are more likely.
The nurse is preparing to change the soiled bed linens of the client with acute diarrhea of unknown origin. Which interventions should the nurse implement? Select all that apply.
- A. Wear a mask while changing the soiled linens
- B. Wear gown and gloves while in the room
- C. Use alcohol-based hand wash before and after care
- D. Request that the HCP prescribe a stool culture
- E. Post an enteric precaution sign outside the room
Correct Answer: B,D,E
Rationale: B: Gown and gloves protect against potential infectious stool. D: A stool culture identifies the cause. E: Enteric precautions prevent transmission. A: Masks are unnecessary for non-airborne pathogens. C: Soap and water are needed for possible C. difficile.