Nokea
By 2nd post-op day, a client has not achieved satisfactory pain relief. Based on this evaluation, what should nurse do next according to nursing process?
- A. Reassess client to determine reasons for unsatisfactory pain relief
- B. See whether pain lessens during next 24h
- C. Change plan to ensure client achieves adequate pain relief
- D. Teach client about plan of care for managing his pain
Correct Answer: A
Rationale: The correct answer is A. In the nursing process, the first step in addressing a client's unsatisfactory pain relief is to reassess the client to determine the reasons for it. This involves evaluating the pain intensity, location, characteristics, aggravating factors, and the client's response to current pain management interventions. By reassessing, the nurse can identify any underlying causes contributing to the lack of pain relief and adjust the plan of care accordingly.
Choice B is incorrect because waiting another 24 hours without further assessment delays appropriate intervention. Choice C is incorrect as changing the plan without reassessment may not address the root cause of the issue. Choice D is incorrect as teaching the client about the plan of care should come after reassessment to ensure it is tailored to the client's specific needs.
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Nurse providing pre-op teaching for client scheduled for mastectomy next day. Which client statement indicates client is ready to learn?
- A. I don't want my spouse to see my incision
- B. Will you be able to give me pain meds after surgery?
- C. Can you tell me about how long the surgery will take?
- D. My roommate listens to everything I say
Correct Answer: C
Rationale: The correct answer is C because the client's question shows readiness to learn about the procedure, indicating an active interest in understanding the surgery process. This demonstrates the client's engagement and willingness to absorb information, which is crucial for pre-op teaching. Choices A, B, and D do not directly relate to seeking information about the surgery itself and do not demonstrate readiness for learning. Therefore, they are incorrect.
Mother of 7 mo infant tells nurse that her baby has been fussy with occasional loose stools since she started feeding him fruits & veggies. Which responses by nurse are appropriate? (Select all that apply.)
- A. It might be good to add bananas, as they help with loose stools
- B. Let's make list of foods he's eating so we can spot problems
- C. Did the changes begin after you started 1 particular food?
- D. Has he been vomiting since he started these new foods?
- E. Most babies react with indigestion when you start new foods
Correct Answer: B,C,D
Rationale: Correct Answer: B, C, D
Rationale:
B: Making a list of foods eaten helps identify potential triggers causing the baby's symptoms.
C: Asking about specific foods helps pinpoint if a particular food is causing the issues.
D: Inquiring about vomiting helps assess if the baby's symptoms could be due to a more serious underlying issue.
Incorrect Choices:
A: Bananas may not necessarily help with loose stools, and adding new foods without identifying the problem isn't ideal.
E: Not all babies react with indigestion to new foods, making this statement too general and not helpful in this case.
Nurse is caring for many clients during mass casualty event. Which client is highest priority?
- A. Client with crush injuries to chest/abdomen & expected to die
- B. Client with 4-inch laceration to head
- C. Client with partial & full-thickness burns to face, neck, chest
- D. Client with fractured fibula & tibia
Correct Answer: C
Rationale: The correct answer is C because clients with partial & full-thickness burns to face, neck, chest are the highest priority during a mass casualty event. This is due to the potential for airway compromise and risk of respiratory distress. Burns to these areas can cause swelling and compromise the airway, leading to respiratory distress and possible respiratory failure. Immediate intervention is crucial to ensure adequate oxygenation and ventilation. Clients with crush injuries (A) or fractures (D) may have serious injuries but are not at immediate risk of airway compromise. A laceration to the head (B) may require urgent attention but is not as life-threatening as airway compromise.
Nurse caring for client just admitted after falling. This client is oriented 3x & can follow directions. Which action(s) by nurse are appropriate to decrease risk of fall? (Select all that apply.)
- A. Place belt restraint on him when he's sitting on bedside commode
- B. Keep bed in low position with full side rails up
- C. Ensure client's call light is within reach
- D. Provide client with nonskid footwear
- E. Complete fall-risk assessment
Correct Answer: C,D,E
Rationale: Correct Answer: C, D, E
Rationale:
C: Ensuring the client's call light is within reach allows them to easily call for assistance, reducing the risk of falls.
D: Providing the client with nonskid footwear enhances traction, decreasing the likelihood of slipping and falling.
E: Completing a fall-risk assessment helps identify specific factors contributing to the client's fall risk, enabling tailored interventions for prevention.
Incorrect Choices:
A: Placing a belt restraint on the client when sitting on the commode can lead to loss of autonomy and increase agitation, potentially escalating fall risk.
B: Keeping the bed in a low position with full side rails up may restrict the client's movement and independence, leading to frustration and potential attempts to climb out, increasing the risk of falls.
Nurse observes assistive personnel (AP) reprimanding a client for not using urinal properly. The AP tells him she will put a diaper on him if he doesn't use urinal more carefully next time. Which of the following torts is AP committing?
- A. Assault
- B. Battery
- C. False imprisonment
- D. Invasion of privacy
Correct Answer: A
Rationale: The correct answer is A: Assault. Assault is the intentional act that causes another person to fear that they will be touched in a harmful or offensive manner. In this scenario, the AP's threat to put a diaper on the client if he doesn't use the urinal properly next time is an intentional act that instills fear in the client. This threat constitutes assault because it creates a reasonable apprehension of harmful or offensive contact.
Choice B (Battery) involves actual physical contact without consent, which is not present in this scenario. Choice C (False imprisonment) involves restricting someone's freedom of movement, which is not evident here. Choice D (Invasion of privacy) pertains to disclosing private information, which is not the issue at hand. Therefore, the correct answer is A as it best aligns with the scenario presented.