Nokea
A patient with effective pain relief.
Which of the following nursing actions is MOST important to provide a patient with effective pain relief?
- A. Teach the patient about his pain.
- B. Establish a trusting relationship with the patient.
- C. Determine how various relaxation techniques affect the pain.
- D. Provide alternative measures to relieve pain.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not most important (2) correct-necessary to work with patient to identify interventions to relieve pain (3) part of intervention and evaluation phase (4) only a portion of interventions used to relieve pain
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A client who is terminally ill has been receiving high doses of an opioid analgesic for the past month. As death approaches and the client becomes unresponsive to verbal stimuli, what orders would the nurse expect from the health care provider?
- A. Decrease the analgesic dosage by half
- B. Discontinue the analgesic
- C. Continue the same analgesic dosage
- D. Prescribe a less potent drug
Correct Answer: C
Rationale: Continue the same analgesic dosage. Dying patients who have been in chronic pain will probably continue to experience pain even though they cannot communicate their experience. Pain medication should be continued at the same dose, if effective.
A client has been transferred from a nursing home to the hospital with an indwelling urinary catheter. The urine is cloudy and foul-smelling.
Which of the following nursing measures would be MOST appropriate?
- A. Clean the urinary meatus every other day.
- B. Encourage the client to increase fluid intake.
- C. Empty the drainage bag every 2-4 hours.
- D. Irrigate the Foley catheter every 8 hours.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not address the problem of the client's urine, should not be performed (2) correct-increasing intake of fluids is an appropriate independent nursing action that facilitates removal of concentrated urine (3) does not address the problem of the client's urine, should not be performed (4) could increase the chance of developing an infection
A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse 'What is our major concern now, and what will we have to deal with in the future?' Which of the following is the best response?
- A. There is a probability of life-long complications.
- B. Cystic fibrosis results in nutritional concerns that can be dealt with.
- C. Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis.
- D. You will work with a team of experts and also have access to a support group that the family can attend.
Correct Answer: C
Rationale: Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis. Respiratory issues are the primary concern due to chronic lung complications.
After 4 electroconvulsive treatments over 2 weeks, a client is very upset and states 'I am so confused. I lose my money. I just can't remember telephone numbers.' The most therapeutic response for the nurse to make is
- A. You were seriously ill and needed the treatments.'
- B. Don't get upset. The confusion will clear up in a day or two.'
- C. It is to be expected since most clients have the same results.'
- D. I can hear your concern and that your confusion is upsetting to you.'
Correct Answer: D
Rationale: Communicating caring and empathy with the acknowledgement of feelings is the initial response. Afterwards, teaching about the expected short-term effects would be discussed.
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings should the nurse report immediately?
- A. Mild redness at the IV site.
- B. Temperature of 100.8°F (38.2°C).
- C. Urine output of 50 mL/hour.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests worsening infection, requiring immediate reporting. Options A, C, and D are less urgent or normal.