Nokea
You routinely use the PQRST method to assess pain. The PQRST method consists of:
- A. Pain level, the quality of the pain, the region or area of the pain, the severity of the pain, and the pain triggers
- B. Precipitating factors, the quality of the pain, relief factors, the severity of the pain, and the pain triggers
- C. Pain level, the quantitative numerical pain score, the region or area of the pain, the severity of the pain, and the pain triggers
- D. Precipitating factors, the quality of the pain, the region or area of the pain, the severity of the pain, and the pain triggers
Correct Answer: D
Rationale: The PQRST method assesses pain through Precipitating factors, Quality, Region, Severity, and Timing (triggers).
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A client with a history of asthma is prescribed albuterol (Proventil). The nurse should instruct the client to:
- A. Use the inhaler daily to prevent attacks.
- B. Rinse the mouth after each use.
- C. Use the inhaler during an acute attack.
- D. Stop the inhaler if heart palpitations occur.
Correct Answer: C
Rationale: Albuterol is a rescue inhaler used during acute asthma attacks to relieve bronchospasm.
The primary health care provider prescribes 650 mg of an antibiotic to be administered intravenously every 6 hours. The medication label reads as follows: reconstitute with 4.8 mL of bacteriostatic water to yield 2 g in 5 mL. How many mL should the nurse withdraw from the vial for 1 dose? Fill in the blank. Record the answer using 1 decimal place.
Correct Answer: 1.6 mL
Rationale: Convert 2 g to mg and then use the formula for calculating medication doses. In the metric system, to convert larger to smaller, multiply by 1000 or move the decimal 3 places to the right. Therefore, 2 g = 2000 mg. Formula: Desired / Available x Available Volume = 650 mg / 2000 mg x 5 mL = 1.625 mL = 1.6 mL.
A client with a diagnosis of breast cancer is prescribed exemestane (Aromasin). The nurse should instruct the client to report which of the following side effects immediately?
- A. Hot flashes.
- B. Bone pain.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Bone pain may indicate bone loss or metastasis, a serious side effect of exemestane requiring immediate reporting.
A client has soft wrist restraints to prevent her from pulling out her nasogastric tube. Which of the following nursing interventions should be implemented while the restraints are on the client?
- A. Instruct the client not to move while the restraints are in place
- B. Remove the restraints every 4 hours to provide skin care
- C. Secure the restraints to side rails of the bed
- D. Check on the client every 30 minutes while the restraints are on
Correct Answer: D
Rationale: Checking the client every 30 minutes ensures safety, circulation, and skin integrity while restraints are in use. Restraints should be removed every 2 hours for care, not 4, and securing to side rails is unsafe.
A client has had a cardiac catheterization. The left femoral dressing has a moderate amount of bloody drainage, and the client has severe pain in that area. The nurse should first:
- A. Assess the airway.
- B. Administer oxygen.
- C. Apply pressure to the site.
- D. Assess the pulse in the left extremity.
Correct Answer: C
Rationale: Applying pressure to the site controls bleeding, which is the priority in this scenario.