Nokea
During a situation of pain management, which statement is a priority to consider for the ethical guidelines of the nurse?
- A. The client's self-report is the most important consideration
- B. Cultural sensitivity is fundamental to pain management
- C. Clients have the right to pain management
- D. Nurses should not prejudge a client's pain using their own values
Correct Answer: A
Rationale: The client's self-report is the most important consideration. Pain is a complex phenomenon that is perceived differently by each individual. Pain is whatever the client says it is. The other statements are correct but not the most important considerations.
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The nurse is to observe the client for shock. The client's admitting vital signs are blood pressure (BP)=116/70, pulse=86, and respirations=24. Which finding, if observed, would be most suggestive of shock?
- A. BP=140/60
- B. Pulse=100
- C. BP=114/68
- D. Pulse=60
Correct Answer: B
Rationale: Increased pulse (tachycardia) is a hallmark of shock, compensating for reduced volume. Stable or slightly varied BP and low pulse are less indicative.
The nurse is reviewing recommended dietary modifications with a client with celiac disease. Which of the following menu selections by the client would indicate a correct understanding of the teaching? Select all that apply.
- A. Beef barley soup with mixed vegetables and French bread
- B. Corn tortilla tacos with ground beef and cheese
- C. Grilled chicken, baked potato, and strawberry yogurt
- D. Peanut butter and jelly on whole wheat bread and an apple
- E. Rice noodles with chicken and broccoli
Correct Answer: B,C,E
Rationale: Corn tortillas, grilled chicken with potato/yogurt, and rice noodles are gluten-free, suitable for celiac disease. Barley and wheat contain gluten.
An adult woman has been diagnosed with varicose veins. Which aspect of her history is most likely related to her diagnosis?
- A. She has had five term pregnancies.
- B. She runs several marathons a year.
- C. She is 5 feet, 6 inches tall and weighs 120 pounds.
- D. She works entering data into a computer.
Correct Answer: A
Rationale: Multiple pregnancies increase intra-abdominal pressure and venous stasis, contributing to varicose veins. Running, normal weight, and sedentary work are less directly related.
Which of the following drug administrations should be reported as a practice error? Select all that apply.
- A. Cephalexin administered; client has history of anaphylaxis from penicillin
- B. Hydromorphone 2 mg administered; client reports pruritus
- C. Immunization for 3-month-old administered in ventrogluteal site
- D. Oral niacin (nicotinic acid) administered; client has facial flushing
- E. Warfarin administered; client at 12 weeks gestation
Correct Answer: A,E
Rationale: Cephalexin in a penicillin-allergic client risks anaphylaxis, and warfarin in pregnancy can cause fetal harm. Pruritus and flushing are expected side effects, and the ventrogluteal site is appropriate.
The nurse is caring for a client newly prescribed crutches. Which finding indicates the need for further teaching?
- A. The axillary pads are torn and show signs of wear
- B. The client has a 30-degree bend at the elbow when walking
- C. The crutches and injured foot are moved simultaneously in a 3-point gait
- D. There is a 3 finger-width space noted between the axilla and axillary pad
Correct Answer: A
Rationale: Torn axillary pads can cause discomfort and injury, indicating a need for replacement and further teaching.