Nokea
The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?
- A. Review the client's medical history and admission assessment.
- B. Compare the client's current vital signs to the admission baseline.
- C. Note how frequently doses of analgesics have been administered.
- D. Ask the client to describe the intensity of the pain being experienced.
Correct Answer: D
Rationale: Client self-report is the gold standard for pain severity.
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While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?
- A. C-reactive protein level
- B. Serum potassium and sodium levels
- C. Neutrophil count
- D. Platelet count
Correct Answer: A
Rationale: CRP indicates inflammation, but neutrophils are more specific for infection.
The nurse retrieves hydromorphone '4 mg/mL' from the electronic medication system, for a patient who is receiving hydromorphone 3 mg IM every 6 hours PRN for severe pain. How many mL should the nurse administer to the patient? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)
Correct Answer: 0.8
Rationale: 3 mg ÷ 4 mg/mL = 0.75 mL, rounded to 0.8 mL.
The nurse observes an unlicensed assistive personnel (UAP) providing care for two clients using the same gloves. Which action should the nurse take first?
- A. Praise the UAP for using standard precautions.
- B. Instruct the UAP to change gloves immediately.
- C. Request that an in-service program be scheduled on asepsis.
- D. Submit an adverse occurrence report to the unit manager.
Correct Answer: B
Rationale: Changing gloves prevents cross-contamination.
When conducting diet teaching for a client who is on a postoperative clear liquid diet, which foods should the nurse encourage the client to consume?
- A. Oatmeal, cream of wheat, pureed liquid.
- B. Pureed beans, liquid protein supplements, milkshake.
- C. Pureed carrots, creamed soup, ice cream.
- D. Carbonated drinks, gelatin, broth.
- E. Water, tea, ice chips.
Correct Answer: D,E
Rationale: Clear liquids are transparent and easily digested.
The nurse is entering prescriptions for laboratory work in a client's electronic medical record (EMR) when the system locks up and does not restart. Which action should the nurse take first?
- A. Print the electronic medical record (EMR) from a backup server.
- B. Identify information as a late entry in the record.
- C. Wait for notification that the system has been rebooted.
- D. Notify the information services department of the situation.
Correct Answer: D
Rationale: Notifying IT resolves system issues promptly.