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You are caring for a client who has just returned from surgery and has received intravenous morphine minutes before leaving the recovery room. You need to assess the client's pain now and again at which of the following times?
- A. in 20 to 30 minutes
- B. in one hour
- C. in two hours
- D. in 3 to 4 hours
Correct Answer: A
Rationale: Post-morphine pain assessment at 20-30 minutes evaluates peak effect, critical post-surgery. Later checks miss this window. Nurses time this for efficacy.
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An adult client is on extreme pain. He is moaning and grimacing. What is the best way to assess the client's pain?
- A. Perform physical assessment
- B. Have the client rate his pain on the smiley pain rating scale
- C. Active listening on what the patient says
- D. Observe the client's behavior
Correct Answer: B
Rationale: Rating pain on a smiley scale (B) is best for an adult in extreme pain; it quantifies subjective experience, per pain assessment tools. Physical assessment (A) is secondary, listening (C) misses rating, observing (D) lacks precision. B captures intensity, making it correct.
The nurse allowed Mr. Gary to pray before his procedure as per his cultural practice. This is an example of?
- A. Cultural imposition
- B. Cultural competence
- C. Cultural ignorance
- D. Cultural bias
Correct Answer: B
Rationale: Allowing prayer per Mr. Gary's practice is cultural competence (B) respecting beliefs, per care standards. Imposition (A) forces norms, ignorance (C) neglects, bias (D) prejudges. B reflects adaptive, respectful care, ensuring his spiritual needs are met, making it correct.
The nurse is caring for a client receiving oxygen therapy via a simple face mask. Which nursing intervention is important to prevent skin breakdown?
- A. Changing the position of the mask every 2 hours
- B. Applying a protective barrier cream to the client's face
- C. Padding the pressure points on the client's face with soft material
- D. Encouraging the client to remove the mask intermittently for facial skin care
Correct Answer: C
Rationale: Padding pressure points with soft material (C) prevents skin breakdown from a simple face mask by reducing friction and pressure on the face. Repositioning q2h (A) helps but isn't enough alone. Barrier cream (B) is for moisture, not pressure. Intermittent removal (D) disrupts therapy. Padding, per skin integrity standards, is proactive.
The nurse prepares to administer buccal medication. The medicine should be placed...
- A. On the client's skin
- B. Between the client's cheeks and gums
- C. Under the client's tongue
- D. On the client's conjunctiva
Correct Answer: B
Rationale: Buccal medication is placed between the cheeks and gums for absorption.
You are doing the evaluation step of the nursing process and find that two of the goals for the client have not been met. Which of the following actions would be best on your part?
- A. Stop working on these goals, as evaluation is the last step.
- B. Assess client's motivation for complying with the care plan.
- C. Reassess problem and then review care plan and revise as needed.
- D. Determine if the client has a knowledge deficit causing nonattainment.
Correct Answer: C
Rationale: When goals aren't met during evaluation, reassessing the problem and revising the care plan is the best action. This step identifies why outcomes like reduced swelling failed, perhaps due to an outdated intervention, and adjusts accordingly. Stopping assumes evaluation ends the process, ignoring its cyclical nature. Assessing motivation or knowledge deficits might inform revisions but isn't comprehensive without reassessment. This approach ensures care evolves with the client's condition, maintaining relevance and efficacy in the nursing process.