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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

The correct answer is: c. Positioning the client’s arm above heart level.

Choice A: Wrapping the cuff too loosely around the client’s arm

Wrapping the cuff too loosely can lead to an inaccurately high blood pressure reading, not a low one. A loose cuff does not compress the artery properly, causing the device to overestimate the pressure needed to occlude the artery.

Choice B: Measuring blood pressure right after the client’s mealtime

Measuring blood pressure right after a meal can cause a slight increase in blood pressure due to the body’s metabolic response to digestion. This is not a common cause of a low blood pressure reading.

Choice C: Positioning the client’s arm above heart level

Positioning the client’s arm above heart level can lead to an inaccurately low blood pressure reading. When the arm is elevated, the hydrostatic pressure decreases, resulting in a lower reading. This is a well-known source of error in blood pressure measurement.

Choice D: Deflating the cuff too slowly

Deflating the cuff too slowly can cause venous congestion, which may lead to an inaccurately high reading rather than a low one. The standard deflation rate is 2-3 mm Hg per second to ensure accurate measurement.

A. Protective B. Contact C. Airborne

Correct Answer is D

Explanation

Choice A reason: Protective precautions are used to shield immunocompromised patients from infections, not typically for patients with meningococcal pneumonia.

Choice B reason: Contact precautions are used for infections that are spread by direct contact with the patient or the patient's environment. Meningococcal pneumonia is not primarily spread this way.

Choice C reason: Airborne precautions are for diseases that are spread through the air over long distances, such as tuberculosis. Meningococcal pneumonia is not spread in this manner.

Choice D reason: Droplet precautions are recommended for meningococcal pneumonia. This infection can be spread through droplets from the respiratory tract when the infected person coughs or sneezes. Therefore, droplet precautions, including the use of masks, are necessary to prevent the spread of this infection.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?

Correct Answer is C

Explanation

Choice A: Wrapping the cuff too loosely around the client’s arm

Choice B: Measuring blood pressure right after the client’s mealtime

Choice C: Positioning the client’s arm above heart level

Choice D: Deflating the cuff too slowly

A nurse is assisting with the admission of a client who has meningococcal pneumonia. Which of the following isolation precautions should the nurse initiate?

Correct Answer is D

Explanation

A nurse is removing a wound dressing that is saturated with blood and purulent drainage. Which of the following methods should the nurse use when disposing of the soiled dressing?

A nurse is reinforcing teaching with a newly licensed nurse about documenting vital signs. Which of the following documentation made by the nurse indicates an understanding of the teaching?

Before palpating the abdomen during an assessment, the nurse should do which of the following?

For documenting vital signs, the following documentation made by the nurse indicates an understanding of the teaching:

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)

A nurse is caring for a client who has a wound infection that contains vancomycin-resistant Enterococcus (VRE). Which of the following types of precautions should the nurse plan to take while caring for this client?

A patient has an elevated temperature. The nurse assesses the patient and finds the skin flushed and very warm. The patient is oriented to person, place, time, and situation, and expresses severe fatigue. The most appropriate nursing action at this time would be to:

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?