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A postoperative client has pain medication ordered PRN for discomfort. During the first assessment, the nurse notes that the client has not received pain medication all day. His vital signs are within normal limits, but he is sweating profusely. He smiles at you while speaking and states that he is not hot but is still experiencing some pain and has been since early this morning. What is the most appropriate nursing action?
- A. Administer the largest dose of pain medication allowed because he has been without it all day and then allow him to rest undisturbed.
- B. Administer the minimum dose of medication and reassess his level of pain 30 minutes after administration.
- C. Hold the pain medication because his vital signs are within normal limits and he is smiling and showing no evidence of being in pain.
- D. Encourage the client to continue to do without pain medication so he won't become addicted to the opioid.
Correct Answer: B
Rationale: Administering the minimum dose and reassessing ensures effective pain management while monitoring response, given diaphoresis and reported pain.
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The nurse manager identifies that time spent by staff in charting is excessive, requiring overtime for completion. The nurse manager states that 'staff will form a task force to investigate and develop potential solutions to the problem, and report on this at the next staff meeting.' The nurse manager's leadership style is best described as
- A. Laissez-faire
- B. Autocratic
- C. Participative
- D. Group
Correct Answer: C
Rationale: Participative. A participative style of management involves staff in decision-making processes. Staff/manager interactions are open and trusting. Most work efforts are joint endeavors.
The nurse is caring for a client with a history of chronic venous insufficiency.
- A. Which intervention is most effective for a client with chronic venous insufficiency?
- B. Apply compression stockings.
- C. Encourage bed rest.
- D. Administer diuretics.
- E. Elevate the head of the bed.
Correct Answer: A
Rationale: Compression stockings improve venous return, reducing edema and stasis in chronic venous insufficiency. Bed rest is discouraged, diuretics are not primary, and head elevation is irrelevant.
An 87-year-old woman is admitted to the acute care hospital for heart failure. The nurse asks about the client's signs and symptoms and obtains vital signs. Considering the client's age, what additional question is most important for the nurse to ask?
- A. How do you manage your bowels?
- B. When was your last menstrual period?
- C. What are your favorite foods?
- D. When was your last tetanus shot?
Correct Answer: D
Rationale: Elderly patients are at risk for tetanus due to waning immunity; assessing vaccination status is critical for infection prevention.
Treatment of sickle cell crises includes the application of:
- A. A heating pad to the joints
- B. An ice pack to the joints
- C. A CPM device to the lower leg
- D. A TENS unit to the back
Correct Answer: A
Rationale: Heat application to joints during sickle cell crises promotes vasodilation, improving blood flow and reducing pain from vaso-occlusion. Ice may worsen vasoconstriction, CPM is irrelevant, and TENS is not standard for sickle cell pain.
The nurse assesses the use of coping mechanisms by an adolescent 1 week after the client had a motor vehicle accident resulting in multiple serious injuries. Which of these characteristics are most likely to be displayed?
- A. Ambivalence, dependence, demanding
- B. Denial, projection, regression
- C. Intellectualization, rationalization, repression
- D. Identification, assimilation, withdrawal
Correct Answer: B
Rationale: Helplessness and hopelessness may contribute to regressive, dependent behavior which often occurs at any age with hospitalization. Denying or minimizing the seriousness of the illness is used to avoid facing the worst situation. Recall that denial is the initial step in the process of working through any loss.