Nokea
Which technique would be most appropriate for the nurse to implement when assessing a four (4)-year-old client in acute pain?
- A. Use words a four (4)-year-old child can remember.
- B. Explain the 0-to-10 pain scale to the child's parent.
- C. Have the child point to the face which describes the pain.
- D. Administer the medication every four (4) hours.
Correct Answer: C
Rationale: The FACES pain scale (pointing to faces) is age-appropriate for a 4-year-old, per pediatric pain assessment guidelines. Simple words are vague, numeric scales are for older children, and scheduled medication is not assessment.
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Which problem would be most appropriate for the nurse to identify for the client experiencing acute pain?
- A. Ineffective coping.
- B. Potential for injury.
- C. Alteration in comfort.
- D. Altered sensory input.
Correct Answer: C
Rationale: Alteration in comfort directly addresses acute pain’s impact, per NANDA-I. Coping, injury, and sensory input are secondary or unrelated.
The PACU nurse administers Narcan, an opioid antagonist, to a postoperative client. Which client problem should the nurse include to the plan of care based on this medication?
- A. Alteration in comfort.
- B. Risk for depressed respiratory pattern.
- C. Potential for infection.
- D. Fluid and electrolyte imbalance.
Correct Answer: B
Rationale: Narcan reverses opioid-induced respiratory depression, but risk persists, requiring monitoring. Comfort, infection, and fluid imbalance are unrelated to Narcan.
Which client would the nurse identify as having the highest risk for developing postoperative complications?
- A. The 67-year-old client who is obese, has diabetes, and takes insulin.
- B. The 50-year-old client with arthritis taking nonsteroidal anti-inflammatory drugs.
- C. The 45-year-old client having abdominal surgery to remove the gallbladder.
- D. The 60-year-old client with anemia who smokes one (1) pack of cigarettes a day.
Correct Answer: A
Rationale: Obesity, diabetes, and insulin use increase risks for infection, poor wound healing, and glycemic instability, the highest risk profile. Arthritis, cholecystectomy, and anemia/smoking are less severe.
Which statement made by the client who is postoperative abdominal surgery indicates the discharge teaching has been effective?
- A. I will take my temperature each week and report any elevation.
- B. I will not need any pain medication when I go home.
- C. I will take all of my antibiotics until they are gone.
- D. I will not take a shower until my three (3)-month checkup.
Correct Answer: C
Rationale: Completing antibiotics prevents infection, a key teaching point. Weekly temperature checks are excessive, pain medication is often needed, and showering is allowed sooner.
The male client in the day surgery unit complains of difficulty urinating postoperatively. Which intervention should the nurse implement?
- A. Insert an indwelling catheter.
- B. Increase the intravenous fluid rate.
- C. Assist the client to stand to void.
- D. Encourage the client to increase fluids.
Correct Answer: C
Rationale: Standing to void facilitates urination by using gravity, a non-invasive first step. Catheterization, IV fluids, and oral fluids are more invasive or secondary.