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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.
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While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively.Which action should the nurse implement?
- A. Demonstrate the skill speaking slowly and using simple terms.
- B. Reassure the client that the skill is not difficult to learn.
- C. Reduce the stimuli in the area before continuing the teaching.
- D. Provide the client with step-by-step written instruction.
Correct Answer: C
Rationale: Sensory overload happens when an individual is getting more input from their senses than their brain can sort through and process. Therefore, reducing the stimuli in the area can help the client's brain to better process the information being taught.
Which descriptions of stool warrant additional follow-up by the nurse? (Select all that apply.).
- A. Solid with red streaks.
- B. Formed but solid.
- C. Brown liquid.
- D. Tarry appearance.
- E. Multiple hard pellets.
Correct Answer: A,C,D,E
Rationale: Solid stool with red streaks may indicate lower gastrointestinal bleeding and requires further evaluation. Brown liquid stool may suggest diarrhea or malabsorption issues, warranting further assessment. A tarry appearance can indicate upper gastrointestinal bleeding and requires prompt follow-up. Multiple hard pellets may indicate constipation or dehydration and should be addressed.
The nurse observes a new employee, an uncertified nursing assistant (UAP), checking the temperature using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer.Which action should the nurse implement?
- A. Remind the UAP to locate the thermometer before gently inserting the ear.
- B. Demonstrate the correct technique for pulling the client's auricle up and back.
- C. Advise the UAP to hold the thermometer securely in place to obtain the measurement.
- D. Use positive reinforcement to affirm that the procedure being performed correctly.
Correct Answer: D
Rationale: The UAP is correctly pulling the client's auricle up and back and preparing to insert the thermometer.
The nurse is using guided imagery with a client who is experiencing chronic pain.What should the nurse direct the client's attention on during the session?
- A. Positive external places.
- B. Motivational phrases.
- C. Tranquil sounds.
- D. Emotional reflection.
Correct Answer: A
Rationale: Guided imagery involves creating a specific imagined reality for yourself. These techniques can be self-taught or guided by a professional. The more you're able to use your imagination and engage your senses, the greater the benefits.
The healthcare provider prescribes ear drops to an adult client with an ear infection.Which exacting should the nurse follow?
- A. Swab and shake bottle before administering the drops.
- B. Administer the drops with the head tilted upright.
- C. Lower the edge of the dropper into the canal of the ear.
- D. Keep the patient in supine position to administer the drops
Correct Answer: D
Rationale: When administering ear drops to an adult client with an ear infection, the nurse should keep the patient in a supine position to administer the drops. This position allows the medication to flow into the ear canal and reach the site of infection.