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When a patient refuses to remove their religious jewelry before surgery, what is the best response for the nurse preparing for the procedure?
- A. Proceed with the surgery and document the refusal.
- B. Ask the patient for permission to secure the jewelry safely.
- C. Tape the jewelry to the patient's body during surgery.
- D. Tell the patient they must remove the jewelry for safety reasons.
Correct Answer: B
Rationale: The best response for the nurse is to ask the patient for permission to secure the jewelry safely. Hospital policy typically requires jewelry to be secured or removed to prevent interference during surgery. Proceeding with the surgery without addressing the issue or taping the jewelry to the patient's body are not safe practices and can lead to complications during the procedure. Directing the patient to remove the jewelry without exploring alternative solutions is not patient-centered care and may create unnecessary tension.
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Which intervention is most effective in managing a patient with chronic pain?
- A. Administer opioid medications as prescribed.
- B. Teach the patient relaxation techniques.
- C. Encourage the patient to perform range of motion exercises.
- D. Recommend complete bed rest to minimize pain.
Correct Answer: B
Rationale: The most effective intervention in managing a patient with chronic pain is teaching the patient relaxation techniques. Relaxation techniques can help reduce stress, decrease muscle tension, and improve pain management in patients with chronic pain. Administering opioids as prescribed may have risks of dependence and side effects, making it less favorable as a first-line intervention. Encouraging range of motion exercises can be beneficial, but relaxation techniques directly target stress reduction, a common exacerbating factor in chronic pain. Recommending complete bed rest is generally discouraged in chronic pain management as it can lead to deconditioning and worsen pain over time.
A client reports severe pain unrelieved by pain medication in a limb with traction. What is the nurse's priority?
- A. Increase the dosage of pain medication.
- B. Assess for compartment syndrome.
- C. Wait for the healthcare provider to address the issue.
- D. Reposition the client to alleviate the pain.
Correct Answer: B
Rationale: The correct answer is B: Assess for compartment syndrome. Severe unrelieved pain in a limb with traction can be a sign of compartment syndrome, a surgical emergency. Prompt assessment is crucial to prevent potential complications. Increasing pain medication dosage without addressing the underlying cause may delay necessary interventions. Waiting for the healthcare provider may lead to a critical delay in treatment. Repositioning the client may not alleviate the pain if it is due to compartment syndrome, and it is crucial to assess for this condition first.
A patient has difficulty ambulating after surgery. Which action should the nurse take first?
- A. Encourage deep breathing exercises.
- B. Assist the patient in ambulating a short distance.
- C. Call for assistance with ambulation.
- D. Assess the patient's pain level before ambulation.
Correct Answer: C
Rationale: The correct first action for the nurse to take when a patient has difficulty ambulating after surgery is to call for assistance with ambulation. This is essential to ensure the safety of the patient and prevent any potential falls or injuries. Encouraging deep breathing exercises (Choice A) may be beneficial but should not be the first priority when the patient is having difficulty walking. Assisting the patient in ambulating a short distance (Choice B) may put both the patient and the nurse at risk if the patient is struggling. Assessing the patient's pain level before ambulation (Choice D) is important but should come after ensuring that the patient can safely ambulate with assistance.
What is the most appropriate method for assessing a patient's pain level?
- A. Observe the patient's facial expressions.
- B. Use a standardized pain scale, such as 0-10.
- C. Ask the patient to rate their pain based on their mood.
- D. Ask the patient's family members to assess the pain.
Correct Answer: B
Rationale: The most appropriate method for assessing a patient's pain level is to use a standardized pain scale, such as a 0-10 scale. This method provides an objective and consistent way to measure and communicate the intensity of pain experienced by the patient. Choice A, observing facial expressions, can be subjective and may not always accurately reflect the level of pain. Choice C, asking the patient to rate their pain based on their mood, may be influenced by various factors unrelated to pain. Choice D, involving the patient's family members in assessing the pain, is not ideal as pain is a subjective experience that should be reported by the patient themselves.
Which nursing action will most likely increase a patient's risk for developing a health care-associated infection?
- A. Uses a sterile bottled solution more than once within a 24-hour period.
- B. Uses surgical aseptic technique to suction an airway.
- C. Uses a clean technique for inserting a urinary catheter.
- D. Uses a cleaning stroke from the urinary meatus toward the rectum.
Correct Answer: C
Rationale: The correct answer is C. Using a clean technique for inserting a urinary catheter increases the risk for healthcare-associated infections. Invasive procedures like catheter insertion require a sterile technique to prevent introducing pathogens into the urinary tract. Choices A and B demonstrate appropriate infection control measures by emphasizing the use of sterile or aseptic techniques. Choice D represents an incorrect technique that can lead to the introduction of bacteria from the rectum into the urinary tract, potentially causing infections.