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A female client who is receiving hospice care in her home expresses fear that dying will be painful. Which action should the nurse take first?
- A. Include caregiver in discussion of pain relief strategies.
- B. Encourage the client to talk about her fear related to pain.
- C. Explain that analgesics will be given whenever needed.
- D. Provide therapeutic touch along with comfort and support.
Correct Answer: B
Rationale: Discussing fears allows personalized reassurance.
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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: IT notification resolves system issues quickly.
The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?
- A. Temperature.
- B. Blood pressure.
- C. Heart rate.
- D. Respiratory rate.
Correct Answer: D
Rationale: Cyanosis indicates oxygenation issues, requiring respiratory assessment.
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.
During the admission assessment to the hospital, a male client reports that he is allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?
- A. Send a list of medication allergies to the pharmacy.
- B. Secure an allergy bracelet around the client's wrist.
- C. Notify the dietary department of the client's fruit allergy.
- D. Place a latex-free supply cart outside the client's room.
Correct Answer: B
Rationale: Allergy bracelet ensures immediate awareness.
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.