Nokea
A client is 2 days post-op from thoracic surgery and is complaining of incisional pain. The client last received pain medication 2 hours ago. He is rating his pain as a 5 on a 1-10 scale. After calling the provider, what is the nurse's next action?
- A. Instruct the client to use guided imagery and slow rhythmic breathing
- B. Provide at least 20 minutes of back massage and gentle effleurage
- C. Encourage the client to watch TV
- D. Place a hot water circulation device, such as an Aqua K pad, to the operative site
Correct Answer: A
Rationale: In this scenario, since no additional pain medication is available, the nurse should recommend non-pharmacological pain management techniques. Guided imagery and slow rhythmic breathing can help the client manage incisional pain effectively. These techniques can provide distraction and relaxation, potentially reducing the perception of pain without the need for additional medication.
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The healthcare professional is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. What action should the healthcare professional take next?
- A. Document that the client responds to a painful stimulus.
- B. Observe the client's response to verbal stimulation.
- C. Place the client on seizure precautions for 24 hours.
- D. Report decorticate posturing to the healthcare provider.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client is being taught how to self-administer a subcutaneous injection. To ensure sterility of the procedure, which subject is most important for the instructor to include in the teaching plan?
- A. Hand washing before preparing the injection.
- B. Technique for drawing medication from a vial.
- C. Selection and rotation of injection sites.
- D. Proper disposal of injection equipment.
Correct Answer: B
Rationale: To maintain the sterility of the procedure, it is crucial to teach the client the correct technique for drawing medication from a vial. This ensures that the medication remains sterile during preparation and administration. While hand washing, injection site selection, and equipment disposal are important aspects of injection safety, the key focus should be on maintaining the sterility of the medication itself to prevent infections and ensure the effectiveness of the treatment.
When measuring vital signs, the healthcare provider observes that a client is using accessory neck muscles during respirations. What follow-up action should the healthcare provider take first?
- A. Determine pulse pressure
- B. Auscultate heart sounds
- C. Measure oxygen saturation
- D. Check for neck vein distention
Correct Answer: C
Rationale: Observing a client using accessory neck muscles during respiration indicates respiratory distress. The priority action should be to measure oxygen saturation to assess the adequacy of oxygenation. This intervention provides crucial information about the client's respiratory status and helps guide further assessment and interventions.
During the suctioning of a tracheostomy tube, if the catheter appears to attach to the tracheal walls and creates a pulling sensation, what is the best action for the nurse to take?
- A. Release the suction by opening the vent.
- B. Continue suctioning to remove obstruction.
- C. Increase the pressure.
- D. Suction deeper.
Correct Answer: A
Rationale: When the catheter of the suctioning device attaches to the tracheal walls, causing a pulling sensation, the nurse should release the suction by opening the vent. This action will alleviate the pulling sensation and prevent trauma to the delicate tracheal walls. Continuing suctioning or applying more pressure can lead to tissue damage and should be avoided. Suctioning deeper can increase the risk of injuring the patient's airway.
A client with a diagnosis of deep vein thrombosis (DVT) is receiving anticoagulation therapy. Which statement by the client indicates a need for further teaching?
- A. I should avoid eating green leafy vegetables.
- B. I should wear loose-fitting clothes to avoid pressure on my legs.
- C. I should avoid prolonged sitting or standing.
- D. I should continue taking my over-the-counter herbal supplements.
Correct Answer: D
Rationale: The statement 'I should continue taking my over-the-counter herbal supplements' (D) indicates a need for further teaching because some herbal supplements can interact with anticoagulants, increasing the risk of bleeding. It is crucial to inform healthcare providers about all medications, including herbal supplements, to prevent adverse interactions. The other statements reflect appropriate understanding of precautions related to DVT and anticoagulation therapy.