Nokea
A client is requesting medicine for pain 30 minutes after receiving morphine sulfate 5 mg intravenously. Which intervention should the nurse implement next?
- A. Ask the UAP to offer a backrub to the client.
- B. Reassess the client and the level of pain.
- C. Tell the client the medication needs more time to work.
- D. Encourage the client to focus on taking deep breaths.
Correct Answer: B
Rationale: Reassessing pain evaluates medication effectiveness.
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Which is the best approach for the nurse to use when interviewing a client about sexuality/reproductive function?
- A. Ask questions in a vague, nonspecific format.
- B. Get the most difficult questions over with first.
- C. Share personal values to put the client at ease.
- D. Begin with questions that are less sensitive in nature.
Correct Answer: D
Rationale: Less sensitive questions build rapport.
Twelve hours following a unilateral total knee replacement, a client reports being unable to sleep because of severe incisional pain. What is the best initial nursing action?
- A. Instruct the client in use of the prescribed patient-controlled analgesia (PCA) pump.
- B. Assist the client in assuming a lateral recumbent position for comfort.
- C. Initiate continuous passive motion (CPM) to relieve muscle spasms.
- D. Apply ice to the incision for twenty minutes prior to joint flexion exercises.
Correct Answer: A
Rationale: PCA pump allows self-administered analgesia for immediate pain relief.
While electronically scanning the client's armband at the bedside prior to administering pain medication, the nurse observes the power flickers and the computer screen goes blank. The computer fails to reboot and the screen remains dark. Which action should the nurse do first?
- A. Notify the information services department of the situation.
- B. Print electronic medical record (EMR) from the backup server.
- C. Identify information as a late entry in the record.
- D. Wait for notification that the system has been rebooted.
Correct Answer: A
Rationale: Notifying IT ensures prompt system resolution.
The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?
- A. Dizziness can occur during cleansing.
- B. Foreskin should not be retracted.
- C. An erection may occur while providing care.
- D. Pubic area should be kept shaved.
Correct Answer: B
Rationale: Non-retractable foreskin should not be forced to prevent discomfort.
A client who is 2 days postoperative for thoracic surgery is reporting incisional pain 2 hours after receiving pain medication. The client rates the pain as 5 on a pain scale of 1 to 10. After placing a call to the healthcare provider, which action should the nurse implement?
- A. Instruct the client to use guided imagery and slow rhythmic breathing.
- B. Place a hot water circulation device, such as an Aqua K pad, to the operative site.
- C. Tune to a television show or easy listening music to provide distraction.
- D. Provide at least 20 minutes of back massage and gentle effleurage.
Correct Answer: A
Rationale: Guided imagery promotes relaxation to manage moderate pain.