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When assessing a client with chronic pain, which of the following is the most reliable indicator of the client's pain?
- A. The client's vital signs.
- B. The client's self-report of pain.
- C. The client's body language.
- D. The client's medical history.
Correct Answer: B
Rationale: The client's self-report of pain is the most reliable indicator of pain. Pain is a subjective experience, and the client's self-report provides direct insight into their perception of pain intensity, quality, and impact on daily life. Vital signs, body language, and medical history can offer additional information but may not accurately reflect the client's actual pain experience. Therefore, relying on the client's self-report ensures a more accurate assessment of their pain and helps in tailoring appropriate interventions and treatment plans.
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What is the primary goal of palliative care?
- A. To cure the client's illness.
- B. To prolong the client's life.
- C. To provide comfort and improve the quality of life.
- D. To prepare the client for surgery.
Correct Answer: C
Rationale: The primary goal of palliative care is to provide comfort and improve the quality of life for clients with serious illnesses. Palliative care aims to address physical, emotional, and spiritual needs to enhance overall well-being rather than focusing on curing the underlying illness, prolonging life, or preparing for surgery. It emphasizes symptom management, pain relief, and support for patients and their families to ensure a better quality of life during the course of their illness.
What action should be taken to prevent respiratory complications in a client who is postoperative?
- A. Encourage the use of an incentive spirometer.
- B. Restrict fluid intake.
- C. Place the client in a supine position.
- D. Administer a cough suppressant.
Correct Answer: A
Rationale: Encouraging the use of an incentive spirometer is crucial in preventing respiratory complications postoperatively. The incentive spirometer helps the client perform deep breathing exercises, which can prevent atelectasis (lung collapse) and promote lung expansion. This, in turn, reduces the risk of respiratory complications such as pneumonia. Restricting fluid intake, placing the client in a supine position, and administering a cough suppressant are not appropriate actions for preventing respiratory complications in a postoperative client.
What action is required by law when preparing to administer a controlled substance?
- A. Verify the client's identification using two identifiers.
- B. Document the medication administration in the client's chart immediately.
- C. Return any unused portion of the medication to the pharmacy.
- D. Have a second nurse witness the disposal of any unused portion.
Correct Answer: D
Rationale: Having a second nurse witness the disposal of any unused portion of a controlled substance is a legal requirement to ensure proper disposal, prevent diversion, and maintain accountability. This practice helps in reducing the risk of misuse or unauthorized access to controlled substances, enhancing patient safety, and complying with legal regulations and standards.
A healthcare provider is planning care for a client who has a pressure ulcer. Which of the following actions should the healthcare provider take?
- A. Massage the reddened area.
- B. Apply a heating pad to the area.
- C. Elevate the head of the bed to 45 degrees.
- D. Reposition the client every 2 hours.
Correct Answer: D
Rationale: Repositioning the client every 2 hours is crucial in preventing pressure ulcers from worsening. This action helps relieve pressure on specific areas, improving circulation and reducing the risk of tissue damage. Massaging the reddened area can further damage the skin, applying heat can increase the risk of skin breakdown, and elevating the head of the bed to 45 degrees may not directly address the pressure ulcer prevention. Proper positioning is essential to avoid prolonged pressure on the affected areas and promote healing.
A healthcare professional is preparing to perform nasotracheal suctioning for a client. Which of the following actions should the healthcare professional take?
- A. Suction during inhalation.
- B. Apply intermittent suction during insertion.
- C. Place the client in a supine position.
- D. Insert the catheter while the client is inhaling.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.