A client with metastatic bone cancer is requesting pain medication. Which approach should the nurse use to assess the quality of the client's pain?

Ask the client to describe the pain.

Identify effective pain relief measures. C. Observe body language and movement.

Provide a numeric pain scale.

Answer and Explanation

The Correct Answer is A

A.   Asking the client to describe the pain allows for a detailed assessment of the pain's quality, location, intensity, and any aggravating or alleviating factors. This information is crucial for tailoring pain management strategies to the client's specific needs.
B.   Identifying effective pain relief measures is important but comes after understanding the pain's characteristics.
C.   Observing body language and movement can provide clues about pain but is subjective and less accurate than direct communication.
D.   A numeric pain scale measures pain intensity but does not provide information about the quality or nature of the pain.

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Correct Answer is ["D","F","I"]

Explanation

A. Administering antipyretic medication as needed is important for managing the client's fever and improving comfort, but not as urgent as monitoring fluid, respiratory status, and cardiac function.
B. Client and family education on fluid management is important but can be addressed after assessing hydration status.
C. Protein restriction might be necessary for CKD management in the long term, but not the most pressing need right now.
D. Given the client's history of chronic kidney disease, monitoring fluid status is crucial to prevent fluid overload and ensure adequate kidney function. Accurate intake and output measurements, along with daily weights, are essential.
E. The bicarbonate level (18 mEq/L) is slightly low, but further investigation can come after addressing the infection.
F. The chest X-ray shows bibasilar infiltrates, and the client has a high respiratory rate.

Continuous assessment of respiratory status is important to detect any signs of respiratory distress or infection, which may require immediate intervention.
G. Performing diagnostic testing to determine cause of fever is necessary for identifying the underlying infection, but secondary to immediate stabilization efforts.
H. Reassessing vital signs is vital for ongoing assessment, but integrated into the monitoring of fluid status, respiratory status, and cardiac function.

I. The client has an elevated potassium level and an irregular heart rate, putting him at risk for cardiac arrhythmias. Continuous ECG monitoring and immediate identification of any arrhythmias are critical to prevent cardiac complications.

A. Propose that the nurse use the antecubital site for IV access. B. Send an unlicensed assistive personnel to gather equipment. C. Direct the nurse to remove the needle before the procedure. D. Suggest starting a secondary infusion at the IV tubing

Correct Answer is C

Explanation

A. Suggesting the antecubital site does not address the immediate issue of using an inappropriate needle size.
B. Sending a UAP to gather equipment is not an immediate action needed to correct the mistake.
C. Using an 18-gauge needle to irrigate an IV catheter is inappropriate and could damage the catheter. The charge nurse should instruct the new nurse to remove the needle and use a syringe without a needle to perform the irrigation safely.
D. Starting a secondary infusion is unrelated to the irrigation process and does not correct the inappropriate needle use.

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A client with metastatic bone cancer is requesting pain medication. Which approach should the nurse use to assess the quality of the client's pain?

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits The healthcare provider has assessed the client and completes initial prescriptions. Which three interventions should the nurse prioritize for this client?

Correct Answer is ["D","F","I"]

Explanation

The charge nurse observes a new nurse preparing to irrigate an intravenous catheter. The new nurse is attaching an 18-gauge needle. Which action should the charge nurse take?

Correct Answer is C

Explanation

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