A nurse in a pediatric unit is planning care for a group of clients. Which of the following clients should the nurse plan to use the Crying, Requires oxygen, Increased vital signs, Expression, Sleeplessness (CRIES) pain scale?

A 10-year-old client who had an appendectomy

A 3-year-old toddler who has a broken elbow

A 4-year-old preschooler who had a tonsillectomy

A 4-day-old infant who had a repair of a birth defect

Answer and Explanation

The Correct Answer is D

Choice A reason: The CRIES pain scale is not suitable for a 10-year-old as this scale is designed for neonates, typically those who are 0 to 6 months old.

Choice B reason: A 3-year-old toddler would be better assessed with a pain scale that allows for their level of understanding and communication, such as the Faces Pain Scale-Revised.

Choice C reason: A 4-year-old preschooler can typically communicate their pain verbally or by using a faces pain scale, making the CRIES scale less appropriate.

Choice D reason: The CRIES pain scale is specifically designed for neonates and is appropriate for assessing pain in a 4-day-old infant who cannot verbally communicate their pain.

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Correct Answer is C

Explanation

Choice A reason: Not wearing artificial nails during client care is a recommended practice to prevent the spread of infection, as artificial nails can harbor bacteria.

Choice B reason: Washing hands when they are visibly dirty is correct, but hand hygiene should also be performed at other times, such as before and after patient contact, regardless of the appearance of cleanliness.

Choice C reason: Changing gloves is not a substitute for hand washing. Hand hygiene is necessary before donning gloves and after removing them to prevent the transmission of pathogens.

Choice D reason: Using alcohol-based hand products is a standard practice in healthcare settings and is effective in killing most bacteria and viruses when the hands are not visibly soiled.

A. Clean the incision with soap and water. B. Perform hand hygiene prior to dressing changes. C. Initiate protective isolation. D. Allow the wound to air periodically.

Correct Answer is B

Explanation

Choice A reason: Cleaning the incision with soap and water is not typically recommended as it can disrupt the healing process and may lead to irritation or infection. The incision should be kept clean and dry, and any cleaning should be done according to the surgeon's instructions.

Choice B reason: Performing hand hygiene before dressing changes is essential in preventing incisional infections. Hand hygiene is one of the most effective ways to prevent the spread of infections, including those at surgical sites.

Choice C reason: Protective isolation is used for immunocompromised patients to protect them from infections, not typically for postoperative patients unless they are at high risk for infection due to other conditions.

Choice D reason: Allowing the wound to air can be part of the healing process, but it must be done carefully and under the guidance of healthcare professionals to ensure that the wound is protected from contamination.

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A nurse in a pediatric unit is planning care for a group of clients. Which of the following clients should the nurse plan to use the Crying, Requires oxygen, Increased vital signs, Expression, Sleeplessness (CRIES) pain scale?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a group of assistive personnel (AP) about hand hygiene. Which of the following statements by an AP should the nurse identify as an indication that the AP requires further teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who is postoperative. Which of the following actions should the nurse take to help prevent an incisional infection?

Correct Answer is B

Explanation

A nurse is monitoring a postoperative client who is unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client is experiencing pain? (Select all that apply)

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