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The nurse finds it difficult to relieve a client's pain satisfactorily. Which of the following measures should the nurse take next when continuing efforts to promote comfort?
- A. Improve the nurse-client relationship.
- B. Enlist the help of the client's family.
- C. Allow the client additional time to work through his or her own responses to pain.
- D. Arrange to have the client share a room with a client who has little pain.
Correct Answer: A
Rationale: Improving the nurse-client relationship fosters trust, enhancing pain management through better communication and tailored interventions. Family help, time, or room sharing are less direct solutions.
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Which of the following positions would be appropriate for a client with severe ascites?
- A. Fowler's.
- B. Side-lying.
- C. Reverse Trendelenburg.
- D. Sims.
Correct Answer: A
Rationale: Fowler's position (A) elevates the head, reducing diaphragm pressure from ascites and improving breathing. Side-lying (B), Reverse Trendelenburg (C), and Sims (D) are less effective for respiratory relief.
A client requests a narcotic analgesic shortly after the oncoming nurse receives change-of-shift report. The nurse who is leaving reported that the client had received morphine 10 mg (IM) within the past hour. The nurse should ask the outgoing RN to do which of the following actions?
- A. Validate with the outgoing RN that morphine 10 mg (IM) had been administered.
- B. Assess the client for manifestations of pain.
- C. Check the medication documentation as to when morphine 10 mg (IM) was dispensed and to whom.
- D. Check to ascertain if any discrepancy had been documented with accompanying reason/s.
Correct Answer: A
Rationale: Validating with the outgoing RN confirms the morphine administration, ensuring safe timing of the next dose and preventing overdose.
The nurse is caring for a client with a new colostomy and notices the client is reluctant to participate in self-care. Which intervention should the nurse implement first?
- A. Teach the client's family to perform colostomy care.
- B. Refer the client to a support group.
- C. Assess the client's barriers to self-care.
- D. Provide written instructions for colostomy care.
Correct Answer: C
Rationale: Assessing the client's barriers to self-care is the first step to understand and address their reluctance, enabling tailored interventions. Teaching family, referring to a support group, or providing instructions are secondary after identifying the underlying issues. CN: Psychosocial adaptation; CL: Synthesize
A client with acute respiratory distress syndrome (ARDS) is on a ventilator. The client's peak inspiratory pressures and spontaneous respiratory rate are increasing, and the PO2 is not improving. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the physician with the recommendation for:
- A. Initiating I.V. sedation.
- B. Starting a high-protein diet.
- C. Providing pain medication.
- D. Increasing the ventilator rate.
Correct Answer: A
Rationale: Increasing peak pressures, respiratory rate, and poor PO2 suggest agitation or asynchrony; I.V. sedation improves ventilator synchrony. Diet and pain medication are irrelevant. Increasing ventilator rate may worsen lung injury.
The nurse is preparing to administer a prescribed medication to a client. The nurse should take which initial action?
- A. Verify the client's full name and date of birth
- B. Ask about any medication allergies
- C. Review the client's vital signs
- D. Review medications and potential interactions
Correct Answer: A
Rationale: Verifying client identity using two identifiers is the initial step to ensure safe medication administration.