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To assess the quality of the client’s abdominal pain, which approach should the nurse use?
- A. Provide a numeric pain scale.
- B. Ask the client to describe the pain.
- C. Observe body language and movement.
- D. Identify effective pain relief measures.
Correct Answer: B
Rationale: Descriptive assessment captures pain quality.
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The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?
- A. Record a palpable systolic pressure of 90 mm Hg.
- B. Release the manometer valve immediately.
- C. Document the absence of the radial pulse.
- D. Inflate the blood pressure cuff to 120 mm Hg.
Correct Answer: D
Rationale: Inflate above pulse disappearance for accuracy.
A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?
- A. Remove dentures or other oral appliance.
- B. Elevate the head of the bed to a 45-degree angle.
- C. Apply the client’s positive airway pressure device.
- D. Put and lock the side rails in place.
Correct Answer: C
Rationale: CPAP prevents airway collapse.
An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep?
- A. Ask the healthcare provider for a mild sedative for bedtime.
- B. Take an afternoon nap to make up for missed sleep.
- C. Drink a mixture of warm water, whiskey, and honey at bedtime.
- D. Establish a regular time for going to bed and getting up.
- E. Avoid drinking caffeinated beverages late in the day.
Correct Answer: D,E
Rationale: Regular schedule and avoiding caffeine improve sleep.
The nurse is interviewing a client with lower abdominal pain and dysuria, and needs to ask the client about sexual activity. Which approach is best for the nurse to use?
- A. Begin with queries that are less sensitive in nature.
- B. Ask queries in a vague, non-specific format.
- C. Get the most difficult queries over with first.
- D. Share personal values to put the client at ease.
Correct Answer: A
Rationale: Less sensitive queries build rapport.
Which intervention should the nurse include in the plan of care for a terminally ill client who is weak, mouth breathing, and refusing anything to eat or drink?
- A. Record the client’s daily weight.
- B. Maintain in high Fowler’s position.
- C. Keep mucous membranes moist.
- D. Report any change in urine color.
Correct Answer: C
Rationale: Moist membranes enhance comfort.