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Which nursing intervention is the highest priority when administering pain medication to a client experiencing acute pain?
- A. Monitor the client's vital signs.
- B. Verify the time of the last dose.
- C. Check for the client's allergies.
- D. Discuss the pain with the client.
Correct Answer: C
Rationale: Checking allergies prevents adverse reactions, the highest safety priority. Vital signs, timing, and pain discussion follow.
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Which nursing task would be most appropriate to delegate to the unlicensed assistive personnel (UAP) on a postoperative unit?
- A. Change the dressing over the surgical site.
- B. Teach the client how to perform incentive spirometry.
- C. Empty and record the amount of drainage in the JP drain.
- D. Auscultate the bowel sounds in all four (4) quadrants.
Correct Answer: C
Rationale: Emptying and recording JP drain output is a technical task within UAP scope. Dressing changes, teaching, and auscultation require nursing judgment.
The 26-year-old male client in the PACU has a heart rate of 110 and a rising temperature and complains of muscle stiffness. Which interventions should the nurse implement? Select all that apply.
- A. Give a back rub to the client to relieve stiffness.
- B. Apply ice packs to the axillary and groin areas.
- C. Prepare an ice slush for the client to drink.
- D. Prepare to administer dantrolene, a smooth-muscle relaxant.
- E. Reposition the client on a warming blanket.
Correct Answer: B,D
Rationale: Tachycardia, hyperthermia, and muscle stiffness suggest malignant hyperthermia; ice packs cool the body, and dantrolene reverses the condition. Back rubs, ice slush, and warming blankets are inappropriate.
The client is complaining of left shoulder pain. Which intervention should the nurse implement first?
- A. Assess the neurovascular status of the left hand.
- B. Check the medication administration record (MAR).
- C. Ask if the client wants pain medication.
- D. Administer the client's pain medication.
Correct Answer: A
Rationale: Assessing neurovascular status rules out referred pain from cardiac or vascular issues, the priority per ABCs. MAR checks, asking about medication, and administration follow.
The client has undergone an abdominal perineal resection of the colon for colon cancer with a left lower quadrant colostomy. Which interventions should the nurse implement? Select all that apply.
- A. Assess the stoma for color every four (4) hours and prn.
- B. Encourage the client to turn, cough, and deep breathe every two (2) hours.
- C. Maintain the head of the bed 30 to 40 degrees elevated at all times.
- D. Auscultate for bowel sounds every four (4) hours.
- E. Administer pain medications sparingly to prevent addiction.
Correct Answer: A,B,D
Rationale: Stoma assessment monitors viability, coughing/deep breathing prevents atelectasis, and bowel sound checks assess GI function. HOB elevation is case-specific, and sparing pain medication risks undertreatment.
The nurse identifies the nursing diagnosis 'risk for injury related to positioning' for the client in the operating room. Which nursing intervention should the nurse implement?
- A. Avoid using the cautery unit which does not have a biomedical tag on it.
- B. Carefully pad the client's elbows before covering the client with a blanket.
- C. Apply a warming pad on the OR table before placing the client on the table.
- D. Check the chart for any prescription or over-the-counter medication use.
Correct Answer: B
Rationale: Padding elbows prevents pressure injuries during positioning, addressing the diagnosis. Cautery, warming pads, and medication checks are unrelated to positioning.