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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 statement should the nurse identify as the expected outcome for a client experiencing acute pain?
- A. The client will have decreased use of medication.
- B. The client will participate in self-care activities.
- C. The client will use relaxation techniques.
- D. The client will repeat instructions about medications.
Correct Answer: B
Rationale: Participating in self-care indicates effective pain control, enabling function, the primary outcome. Medication reduction, relaxation, and instruction repetition are secondary.
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 problem is appropriate for the nurse to identify for a client in the intraoperative phase of surgery?
- A. Alteration in comfort.
- B. Disuse syndrome.
- C. Risk for injury.
- D. Altered gas exchange.
Correct Answer: C
Rationale: Risk for injury (e.g., from positioning, equipment) is a primary intraoperative concern, per NANDA-I. Comfort, disuse, and gas exchange are more postoperative or anesthesia-related.
The nurse is preparing a client for surgery. Which intervention should the nurse implement first?
- A. Check the permit for the spouse's signature.
- B. Take and document intake and output.
- C. Administer the 'on call' sedative.
- D. Complete the preoperative checklist.
Correct Answer: D
Rationale: The preoperative checklist ensures all safety measures (e.g., consent, NPO, allergies) are verified, the first step. Spouse signature, I&O, and sedatives follow checklist completion.
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.