Nokea
The nurses assess the client's pain prior to completing a dressing change. The
client says his current pain is 5/10, but he has pain of 10/10 when his dressing is
changed. What is the priority intervention for this client?
- A. Offer the client protein with meals to promote healing
- B. Remove the old dressing with clean gloves
- C. Teach the client about nonpharmacological pain control methods
- D. Check medication administration record (MAR)for as needed orders (PRN)
Correct Answer: C
Rationale:
You may also like to solve these questions
A nurse is providing teaching to an older client who has osteoarthritis that is
affecting the knees. What statement by the client indicates a correct
understanding of the teaching?
- A. I can use either heat or ice to help relieve the discomfort
- B. The purpose of drug therapy is to stop the disease progression.'
- C. I will start a daily running program to get more exercise.'
- D. I should avoid physical activity to prevent further injury.'
Correct Answer: A
Rationale:
The nurse is planning care for a post-operative client after a total hip
arthroplasty. What is the priority nursing intervention?
- A. Observe client for changes in mental status
- B. Use aseptic technique for wound care and emptying of drains
- C. Keep the client's heels off the bed
- D. Perform neurovascular assessments per protocol
Correct Answer: D
Rationale:
The client is at risk for impaired skin integrity related to the need for several
weeks of bedrest. The nurse evaluates the client after 1 week and finds skin integrity is not impaired. In evaluating the plan of care, what is the nurse's best
action?
- A. Remove the nursing diagnosis in the plan of care since it has not occurred
- B. Change the nursing diagnosis in plan of care to impaired mobility
- C. Modify the nursing diagnosis in plan of care to impaired skin integrity
- D. Keep the nursing diagnosis in the plan of care the same since the risk factors are
still present
Correct Answer: D
Rationale:
The client had surgery one day ago. What assessment is most likely related to
pain?
- A. Blood pressure of 175/90 mm Hg
- B. Respirations of 10 breaths per minute
- C. Heart rate 60 beats/minute
- D. Oxygen saturation of 97%
Correct Answer: A
Rationale:
A provider has ordered a wound culture for a client with a non-healing wound.
What is the nurse's first action?
- A. Label the specimen tube
- B. Put on non-sterile gloves
- C. Gently remove the soiled dressings
- D. Irrigate the wound
Correct Answer: B
Rationale: