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Prior to performing digital removal of a fecal impaction, what is the most important assessment for the nurse to perform?
- A. Abdominal girth.
- B. Breath sounds.
- C. Bowel sounds.
- D. Vital signs.
Correct Answer: D
Rationale: Prior to performing digital removal of a fecal impaction, it is important for the nurse to assess the client's vital signs. This includes checking the client's blood pressure, pulse rate, respiratory rate, and temperature. These measurements can provide important information about the client's overall health status and can help the nurse determine if it is safe to proceed with the procedure.
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While changing the dressing of a client with a leg ulcer, the nurse observes a red, tender, and swollen wound at the site of the lesion.Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?
- A. Hematocrit.
- B. Serum.
- C. Blood PT level.
- D. Neutrophil count.
Correct Answer: D
Rationale: Neutrophils are a type of white blood cell that play a key role in fighting infections. An elevated neutrophil count can indicate the presence of an infection. Therefore, before reporting the finding of a red, tender, and swollen wound at the site of the lesion to the healthcare provider, the nurse should note the client's neutrophil count.
A postoperative client has been prescribed three different analgesics for different levels of pain.What is the most important intervention the nurse should take when administering these medications to the client?
- A. Administer each medication at the same time to ensure pain relief.
- B. Administer the medication with the highest dose first, then the others.
- C. Administer the medications as ordered based on the client's pain level.
- D. Administer the medication with the longest duration of action
Correct Answer: C
Rationale: The most important intervention the nurse should take when administering these medications to the client is to assess the client's pain level and administer the appropriate medication based on the level of pain.
A client arrives at the emergency department (ED) with severe right upper quadrant pain.To assess the quality of the client's pain, which approach should the nurse use?
- A. Ask the client to describe the pain.
- B. Provide a numeric pain scale.
- C. Identify effective pain relief measures.
- D. Observe body language and movement.
Correct Answer: A
Rationale: To assess the quality of the client's pain, the nurse should ask the client to describe the pain. This will help the nurse to understand the characteristics of the pain and how it is affecting the client.
Which response by the nurse is most therapeutic?
- A. Tell me about the visit with your significant other.
- B. I can see that you are feeling lonely.
- C. Would you like to talk for a while?
- D. What did you enjoy about your visit tonight?
Correct Answer: C
Rationale: This response shows that the nurse is willing to listen and provide support to the client. It also allows the client to decide if they want to talk and share their feelings.
The nurse is providing postoperative care for a client who complains of severe pain after receiving codeine 30 mg orally one hour ago.Which intervention should the nurse implement next?
- A. Ask the UAP to offer back rubs to the client.
- B. Reassess the client and the level of pain.
- C. Encourage the client to focus on taking deep breaths.
- D. Tell the client the medication needs more time to work.
Correct Answer: B
Rationale: The nurse should reassess the client's pain level and determine if additional interventions are needed to manage the pain.