Nokea
The nurse is viewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client’s plan of care? Select all that apply.
- A. Encourage increased fluid intake and measure urinary output every 8 hours.
- B. Provide comfort measures such as topical warm application and tactile massage.
- C. Determine client’s objective measure of pain using a numerical pain scale.
- D. Assist the client to ambulate as much as possible during waking hours.
- E. Implement a 24-hour schedule of routine administration of prescribed analgesics.
Correct Answer: B,C,E
Rationale: Comfort, assessment, and analgesics manage pain.
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A client who had emergency gallbladder surgery yesterday is getting ready for discharge. The client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client’s understanding of self-care at home?
- A. Have the client demonstrate prescribed wound care.
- B. After each instruction, ask if the client understands.
- C. Have an interpreter repeat the wound care instructions.
- D. Provide written instructions in the client’s native language.
Correct Answer: A
Rationale: Demonstration confirms skill.
A client voided clear, yellow urine.
- A. The client is dehydrated.
- B. The client has a urinary tract infection.
- C. The client has normal urine output.
- D. The client has kidney stones.
Correct Answer: C
Rationale: Clear, yellow urine indicates hydration.
The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?
- A. Verify placement of pulse oximeter.
- B. Increase the oxygen to 3 L/minute.
- C. Remove nasal cannula.
- D. Switch to a non-rebreather mask.
Correct Answer: A
Rationale: Verifying placement ensures accurate readings.
What times should the nurse measure vital signs? Select all that apply.
- A. 800
- B. 1000
- C. 1200
- D. 1400
- E. 1600
Correct Answer: A,C,E,G
Rationale: Every 4 hours is standard.
Which assessment should the nurse document when charting by exception?
- A. Active bowel sounds in the lower right quadrant.
- B. Contraction of the left pupil when light shines in the right eye.
- C. Basilar lung sounds that are diminished in the left lung.
- D. Capillary refill of 2 seconds in the lower right foot.
Correct Answer: C
Rationale: Abnormal findings are documented.