Nokea
A nurse is collecting data from a client about her current pain status. Which of the following questions should the nurse ask to determine the quality of the client's pain?
- A. Do you have any pain this morning?
- B. Is your pain the same as it has been?
- C. Could you rate your pain on a scale from 0 to 10?
- D. What does your pain feel like?
Correct Answer: D
Rationale: Asking 'What does your pain feel like?' assesses the quality (e.g., sharp, dull), a key component of pain assessment.
You may also like to solve these questions
A nurse is reinforcing teaching with a 30-year-old client who is concerned about cervical cancer. Which of the following statements should the nurse make?
- A. Cervical cancer screenings should begin at age 40
- B. Plan to continue cervical cancer screenings for the rest of your life.
- C. You should get a Papanicolaou (Pap) test and human papillomavirus test every 5 years.
- D. If you are immunized against human papillomavirus, you don't need cervical cancer screenings.
Correct Answer: C
Rationale: For a 30-year-old, Pap and HPV testing every 5 years is recommended per current guidelines, making this the correct statement.
A nurse is reinforcing teaching with a client who has gastroesophageal reflux (GERD). Which of the following statements by the client indicates an understanding of the teaching?
- A. I will lie down for 30 minutes after each meal.
- B. I will increase vitamin C intake by drinking orange juice.
- C. I will sleep flat on my back at night.
- D. I will eat six small meals each day.
Correct Answer: D
Rationale: Eating six small meals reduces stomach pressure and reflux, indicating understanding of GERD management.
A nurse is caring for a client who has a tracheostomy tube. Upon data collection, the nurse observes the client is restless and hears crackles in the lungs. Which of the following interventions should the nurse take?
- A. Perform suctioning.
- B. Instill saline into the tubing.
- C. Increase the humidification.
- D. Check the cuff pressure.
Correct Answer: A
Rationale: Restlessness and crackles in the lungs suggest secretions in the airway, and suctioning is the appropriate intervention to clear them in a client with a tracheostomy.
A nurse is assisting in the care of a client who is in the emergency department (ED) following a ski accident.
Nurses' Notes
Vital Signs
Diagnostic Results
Day 1:
Client brought to the emergency department (ED) following a fall that occurred while downhill skiing. Client states they fell when turning to avoid hitting another skier. Client reports feeling a severe, sudden pain of the right leg upon falling. Right leg was immobilized at the scene and the client transported to the ED.
Client states they were wearing a helmet while skiing. Client reports no headache or loss of consciousness.
Client reports pain as 10 on a scale of 0 to 10 to the right lower leg just below the knee and is unable to bear weight.
Right proximal tibia ecchymotic and swollen below the knee. Area is painful to touch. Open area noted on skin with bone visible. Right knee appears displaced. Left pedal pulses 3+, foot warm with intact movement and sensation. Right pedal pulses 1+, foot cool to palpation with minimal movement and reduced sensation.
The nurse is collecting data on the client. Which of the following findings require follow up?
- A. Findings of right lower extremity assessment
- B. Pain level
- C. Level of consciousness
- D. Oxygen saturation
- E. Right pedal pulses
- F. Temperature
- G. X-ray results
Correct Answer: A,B,E
Rationale: Right lower extremity findings (swelling, open wound), severe pain, and weak right pedal pulses indicate potential fracture or vascular compromise needing follow-up.
A nurse is assisting in the care of a client following a tonsillectomy who is alert and has an SpO2 of 93% on room air. Which of the following actions should the nurse take?
- A. Obtain the client's peak expiratory flow volume.
- B. Encourage the client to cough.
- C. Place the client in a semi-Fowler's position.
- D. Encourage the client to use a straw to sip cool liquids.
Correct Answer: C
Rationale: Placing the client in a semi-Fowler's position promotes airway clearance and comfort post-tonsillectomy, especially with an SpO2 of 93%.