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A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0-10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching they received about pain management?
- A. "It might help me to listen to music while I'm lying in bed."
- B. "I will use the pain medication as prescribed to manage the pain."
- C. "I will request a different type of pain medication if the pain persists."
- D. "I will ask for a physical therapist to help with the pain."
Correct Answer: A
Rationale: The correct answer is A. Listening to music is a non-pharmacological method to help manage mild pain, reflecting an understanding of pain management strategies. It shows the client's grasp of non-pharmacological pain management techniques taught preoperatively. Choice B, while important, only addresses pharmacological pain management, omitting other strategies discussed in preoperative teaching. Choice C jumps to changing medications without considering non-pharmacological methods first, indicating a narrow approach to pain management. Choice D involves a physical therapist, which is not directly related to the pain management strategies typically discussed in preoperative teaching.
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A client returning from the surgical suite following a vaginal hysterectomy is awake and asking for something to drink. Her post-op diet prescription reads: 'clear liquids, advance diet as tolerated.' Which of the following is appropriate for the nurse to tell the patient?
- A. ''I am going to listen to your abdomen.''
- B. ''You need to wait until the surgeon evaluates your condition.''
- C. ''You can have clear liquids, but let me check with the surgeon first.''
- D. ''It is best to start with small sips of clear liquids and observe how you feel.''
Correct Answer: A
Rationale: The correct answer is A: ''I am going to listen to your abdomen.'' Listening to the abdomen helps assess bowel sounds and ensure that the client's gastrointestinal system is ready for oral intake. Choice B is incorrect because the client does not necessarily need to wait for the surgeon to evaluate before starting with clear liquids. Choice C is incorrect because unless there are specific contraindications, clear liquids are usually allowed after surgery. Choice D is incorrect as it does not address the immediate assessment needed before initiating oral intake post-operatively.
When explaining the procedure for collecting a 24-hour urine specimen for creatinine clearance to an older adult male, what should the nurse do next?
- A. Assess the client for confusion and reteach the procedure
- B. Check the urine for color and texture
- C. Empty the urinal contents into the 24-hour collection container
- D. Discard the contents of the urinal
Correct Answer: A
Rationale: The correct next step for the nurse is to assess the client for confusion and reteach the procedure. This is crucial to ensure that the older adult male understands the process correctly, reducing the likelihood of errors in collecting the 24-hour urine specimen for creatinine clearance. Checking the urine for color and texture (Choice B) is not the immediate next step as the focus should be on patient understanding first. Emptying the urinal contents into the 24-hour collection container (Choice C) assumes prior knowledge on the client's part and skips the critical step of ensuring comprehension. Discarding the contents of the urinal (Choice D) is incorrect and wasteful since the urine is necessary for the 24-hour collection process.
Which statement by the mother indicates that the mother understands safety precautions with her four-month-old infant and her 4-year-old child?
- A. I secure the infant car seat in the back seat facing backwards.
- B. I place my infant in the middle of the living room floor on a blanket to play with my 4-year-old while I make supper in the kitchen.
- C. My sleeping baby looks adorable in the crib with the little buttocks up in the air while the four-year-old naps on the sofa.
- D. I have the 4-year-old hold and help feed the four-month-old a bottle in the kitchen while I make supper.
Correct Answer: D
Rationale: Choice D is the correct answer because having the 4-year-old help feed the four-month-old a bottle in the kitchen while the mother makes supper shows supervision of the infant by the older child in a safe environment. This choice indicates that the mother understands safety precautions by involving the older child in a caregiving task under her supervision. Choices A, B, and C are incorrect because they involve unsafe practices such as placing the infant on the floor unsupervised, positioning the infant car seat in the front seat, and not providing direct supervision of the children during naptimes.
A group of newly licensed nurses is being taught about the Braden Scale by a nurse. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?
- A. "The client's age is not a factor in the measurement."
- B. "The scale measures six elements."
- C. "A lower score indicates a higher risk of pressure ulcers."
- D. "Each element is scored on a range from 1 to 4 points."
Correct Answer: B
Rationale: Choice B is the correct answer because the Braden Scale measures six elements: Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction, and Shear. The other choices are incorrect because: Choice A states that the client's age is not a factor in the measurement, which is accurate as age is not included in the Braden Scale. Choice C incorrectly states that a lower score indicates a higher risk of pressure ulcers, which is the opposite of how the Braden Scale works. Choice D inaccurately describes the scoring range of each element on the Braden Scale, which is not from 1 to 4 points but rather from 1 to 3.
When assessing a client's skin turgor, a nurse should:
- A. Grasp a fold of the skin on the chest under the clavicle, release it, and note the depth of the impression
- B. Check skin elasticity on the back of the hand
- C. Press on the skin over the abdomen
- D. Measure skin turgor on the lower leg
Correct Answer: A
Rationale: Correct answer: When assessing a client's skin turgor, a nurse should grasp a fold of the skin on the chest under the clavicle, release it, and note the depth of the impression. This method is reliable for evaluating hydration status as it is less influenced by age-related skin changes or adipose tissue. Choice B, checking skin elasticity on the back of the hand, is not the preferred method for assessing skin turgor. Choice C, pressing on the skin over the abdomen, is not a standard location for assessing skin turgor. Choice D, measuring skin turgor on the lower leg, is not a recommended site for assessing skin turgor in clinical practice.