Nokea
The nurse is assessing a client with a history of chronic pain. Which chronic pain assessment focuses on wellness?
- A. Birth history, immunizations, as well as growth and development
- B. Medical history, chronic pain symptoms, and psychosocial factors.
- C. Religion
- D. Sensory deficits, pain management, medication history
Correct Answer: B
Rationale: A wellness-focused chronic pain assessment includes medical history, pain symptoms, and psychosocial factors to optimize quality of life. Birth history, religion, or sensory deficits alone are insufficient.
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The nurse is caring for a client immediately postoperative following a below-the-knee amputation. The nurse should take which priority action?
- A. Elevate the stump on a pillow
- B. Check the operative site for bleeding
- C. Obtain an order for a physical therapy order
- D. Demonstrate the use of incentive spirometry (IS)
Correct Answer: B
Rationale: Checking the operative site for bleeding is the priority to detect hemorrhage, a life-threatening complication in the immediate postoperative period. Elevating the stump may be contraindicated to prevent contractures, physical therapy orders are not immediate, and incentive spirometry, while important, is secondary to hemorrhage control.
The nurse is caring for a client with the following clinical data. Based on the clinical data, the nurse should clarify which order with the primary healthcare provider (PHCP)
- A. Urine analysis (UA)
- B. Head CT Scan
- C. Regular diet
- D. Ammonia level
Correct Answer: C
Rationale: A regular diet prescription should be questioned because of the client's medical history of diabetes mellitus and hypertension. The appropriate diet would be one restricted in carbohydrates and sodium. Thus, the nurse should follow up with the PHCP regarding this order.
Ergonomic principles are most closely associated with:
- A. Normal bodily alignment
- B. The control of infection
- C. Preventing congenital abnormalities
- D. Preventing hospital-acquired infections
Correct Answer: A
Rationale: Ergonomics focuses on optimizing bodily alignment to reduce strain. Infection control and congenital abnormalities are unrelated.
Item 1 of 1 • Assessment
Neurological: Alert and Oriented x 4; anxious affect
Cardiovascular: S1, S2 heart tones; all peripheral pulses palpable; no edema
Gastrointestinal: Distended abdomen; absent bowel sounds; hiccups; reports persistent nausea
Genitourinary: Denies dysuria; voiding every 3-4 hours with straw-colored urine
Musculoskeletal: Full range of motion in all extremities; steady gait
Integumentary: Incision is approximated; moderate dry sanguineous drainage was noted on the dressing.
Pain: Reports incision pain as a 3 based on a scale of 0-10.
• Vital Signs
Blood Pressure 119/75 mm Hg
Temperature 99° F (37° C)
Heart rate 90/min
Respiratory rate 17 breaths per minute
Oxygen saturation 97% on room air
The nurse is caring for a client two days postoperative following a partial colectomy.Complete the sentence below from the list of options: The client is at risk of developing
--------------based on the client’s------------------------
- A. paralytic ileus
- B. wound infection
- C. intractable pain
- D. integumentary assessment
- E. pain assessment
- F. gastrointestinal assessment
Correct Answer: A,F
Rationale: The client exhibits signs of paralytic ileus, as evidenced by the gastrointestinal assessment findings (distended abdomen, absent bowel sounds, nausea, and hiccups).
The clinical data do not support wound infection as it is too early in the postoperative period for this to occur, and the client has no other manifestations supporting this finding.
Pain is expected in the postoperative period, and the current pain rating is mild-to-moderate (3). In contrast, intractable pain would be suggested by pain not relieved by medication and at a severe level.
The nurse is caring for a client who is 24 hours postoperative following a left total knee replacement. Which assessment data would indicate that the client is ready for discharge?
- A. Pulse (P) 102, RR 18, BP 104/72 mm Hg
- B. Urine output of 200 mL in the past 8 hours
- C. Lung bases are clear upon auscultation
- D. The client rates left knee pain as 8/10 on the Numerical Rating Scale
Correct Answer: C
Rationale: Clear lung bases indicate no respiratory complications, such as pneumonia, which is critical for discharge readiness. A pulse of 102 and low blood pressure (104/72 mm Hg) suggest possible instability, requiring further evaluation. Low urine output (200 mL/8 hours) indicates potential renal issues, and severe pain (8/10) suggests inadequate pain control, both contraindicating discharge.