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A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse’s initial action in response to these observations?
- A. Proceed to the next patient’s room to make rounds.
- B. Determine the patient does not want any pain medicine.
- C. Ask the patient about the facial grimacing with movement.
- D. Administer the pain medication ordered for moderate to severe pain.
Correct Answer: C
Rationale: The correct initial action is to choose C: Ask the patient about the facial grimacing with movement. This is important as the patient's non-verbal cues (facial grimacing) contradict their verbal pain report. By directly addressing the discrepancy, the nurse can gather more accurate information about the patient's pain experience and potentially identify any underlying issues causing the discrepancy.
Proceeding to the next patient's room (A) without addressing the discrepancy would neglect the patient's needs. Assuming the patient does not want pain medicine (B) based solely on the verbal report without further assessment is premature. Administering pain medication (D) without clarifying the situation may lead to inappropriate or ineffective treatment. Therefore, option C is the most appropriate initial action to ensure comprehensive and individualized patient care.
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A client with suspected lung cancer is scheduled for thoracentesis as part of the diagnostic workup. The nurse reviews the client’s history for conditions that might contraindicate this procedure. Which condition is a contraindication for thoracentesis?
- A. A seizure disorder
- B. Anemia
- C. Chronic obstructive pulmonary disease
- D. A bleeding disorder
Correct Answer: D
Rationale: The correct answer is D: A bleeding disorder. Thoracentesis involves inserting a needle into the pleural space to remove fluid. A bleeding disorder increases the risk of excessive bleeding during the procedure. This can lead to complications such as hematoma formation, pneumothorax, or even life-threatening bleeding. It is crucial to assess and address bleeding disorders before performing thoracentesis to ensure the safety of the client.
A: A seizure disorder is not a contraindication for thoracentesis unless uncontrolled seizures could compromise the safety of the procedure.
B: Anemia alone is not a contraindication for thoracentesis, as it does not directly increase the risk of complications during the procedure.
C: Chronic obstructive pulmonary disease is not a contraindication for thoracentesis unless it is severe and compromises the client's ability to tolerate the procedure.
A charge nurse is evaluating a new nurse’s plan of care. Which finding will cause the charge nurse to follow up? Assigning a documented nursing diagnosis of Risk for infection for a patient on
- A. intravenous (IV) antibiotics
- B. Completing an interview and physical examination before adding a nursing diagnosis
- C. Developing nursing diagnoses before completing the database
- D. Including cultural and religious preferences in the database
Correct Answer: C
Rationale: The correct answer is C: Developing nursing diagnoses before completing the database. This is incorrect because developing nursing diagnoses should be based on a comprehensive assessment and analysis of the patient's data. By developing nursing diagnoses before completing the database, the new nurse may overlook important information that could impact the accuracy of the diagnosis and subsequent care plan.
Choice A (intravenous antibiotics) is incorrect because assigning a nursing diagnosis of Risk for infection for a patient on IV antibiotics is a common and appropriate practice given the increased risk of infection associated with invasive procedures.
Choice B (Completing an interview and physical examination before adding a nursing diagnosis) is incorrect because nursing diagnoses should be developed based on the data collected during the assessment process, which includes the interview and physical examination. It is not necessary to complete the entire assessment before assigning a nursing diagnosis.
Choice D (Including cultural and religious preferences in the database) is incorrect because while it is important to consider cultural and religious preferences in care planning, this does not directly relate to the
A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse’s initial action in response to these observations?
- A. Proceed to the next patient’s room to make rounds.
- B. Determine the patient does not want any pain medicine.
- C. Ask the patient about the facial grimacing with movement.
- D. Administer the pain medication ordered for moderate to severe pain.
Correct Answer: C
Rationale: The correct initial action for the nurse is to ask the patient about the facial grimacing with movement (Choice C). This is because the patient's non-verbal cues (facial grimacing) are contradicting their verbal report of low pain level. By asking the patient directly, the nurse can clarify the discrepancy and gain a better understanding of the patient's actual pain level and needs.
Choice A is incorrect as it disregards the patient's observed discomfort. Choice B assumes the patient does not want pain medicine without clarifying the situation first. Choice D is premature as administering pain medication without further assessment may not be appropriate or safe.
In summary, asking the patient about the facial grimacing is essential to ensure accurate pain assessment and appropriate intervention.
A client with a history of cardiac dysrhythmias is admitted to the hospital with the diagnosis of dehydration. The nurse should anticipate that the physician will order;
- A. A glass of water every hour until hydrated
- B. Small frequent intake of juices, broth, or milk
- C. Short-term NG replacement of fluids and nutrients
- D. A rapid IV infusion of an electrolyte and glucose solution
Correct Answer: B
Rationale: Step-by-step rationale for choice B being correct:
1. Dehydration leads to electrolyte imbalances, which can exacerbate cardiac dysrhythmias.
2. Small frequent intake of fluids like juices, broth, or milk helps in gradual rehydration without overwhelming the cardiovascular system.
3. This approach allows for better absorption of fluids and nutrients, promoting hydration without causing sudden shifts in electrolyte levels.
Summary of why other choices are incorrect:
A: Just drinking a glass of water every hour may not address electrolyte imbalances or provide adequate hydration for a client with cardiac dysrhythmias.
C: NG replacement may not be necessary if the client can tolerate oral intake, and it is more invasive than needed.
D: A rapid IV infusion may lead to sudden changes in electrolyte levels, potentially worsening the dysrhythmias.
A baby is born temporarily immune to the diseases to which the mother is immune. The nurse understands that this is an example of which of the following types of immunity?
- A. Naturally acquired passive immunity
- B. Naturally acquired active immunity
- C. Artificially acquired passive immunity
- D. Artificially acquired active immunity
Correct Answer: A
Rationale: The correct answer is A: Naturally acquired passive immunity. This type of immunity occurs when antibodies are passed from mother to baby through the placenta or breast milk, providing temporary protection. The baby does not produce its antibodies, hence it is passive. Choice B, naturally acquired active immunity, involves the body producing its antibodies after exposure to a pathogen. Choice C, artificially acquired passive immunity, involves receiving preformed antibodies from an external source. Choice D, artificially acquired active immunity, involves the body producing antibodies in response to vaccination.