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A client arrives at the emergency department (ED) with severe right upper quadrant pain.
To assess the quality of the client's pain, which approach should the nurse use?

Ask the client to describe the pain.

Provide a numeric pain scale.

Identify effective pain relief measures.

Observe body language and movement.

Answer and Explanation

The Correct Answer is A

To assess the quality of the client’s pain, the nurse should ask the client to describe the pain.

This will help the nurse to understand the characteristics of the pain and how it is affecting the client.

Choice B is incorrect because providing a numeric pain scale only assesses the intensity of the pain, not its quality.

Choice C is incorrect because identifying effective pain relief measures does not assess the quality of the pain.

Choice D is incorrect because observing body language and movement only provides indirect information about the quality of the pain.

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Correct Answer is C

Explanation

Restate the vital importance of performing hand hygiene. The most effective way to prevent MRSA is frequent hand washing1.

Choice A is incorrect because changing the coccyx dressing after performing routine care does not necessarily prevent the spread of MRSA to others.

Choice B is incorrect because changing the coccyx dressing before performing routine care does not necessarily prevent the spread of MRSA to others.

Choice D is incorrect because performing a coccyx dressing change in the nursing station does not necessarily prevent the spread of MRSA to others.

A. Basilar lung sounds that are diminished in the left lung. B. Contraction of the left pupil when light shines in the right eye. C. Capillary refill of 2 seconds in the lower right foot. D. Active bowel sounds in the lower right quadrant.

Correct Answer is A

Explanation

Charting by exception means that the nurse only documents findings that deviate from the established norm or expected outcome.

In this case, the nurse should document the assessment that is not within normal limits, which is “Basilar lung sounds that are diminished in the left lung.”

Choice B is not the answer because contraction of the left pupil when light shines in the right eye is a normal finding known as consensual pupillary response.

Choice C is not the answer because capillary refill of 2 seconds in the lower right foot is a normal finding.

Choice D is not the answer because active bowel sounds in the lower right quadrant are a normal finding.

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A client arrives at the emergency department (ED) with severe right upper quadrant pain. To assess the quality of the client's pain, which approach should the nurse use?

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Correct Answer is A

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A client arrives at the emergency department (ED) with severe right upper quadrant pain.
To assess the quality of the client's pain, which approach should the nurse use?