A nurse is assessing a client who reports acute pain. The nurse should anticipate which of the following findings?

Decreased heart rate.

Hyperactive bowel sounds.

Decreased blood pressure.

Increased respiratory rate.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Decreased heart rate is not an anticipated finding in response to acute pain. Pain typically triggers sympathetic nervous system activation, leading to an increased heart rate as a physiological response to the stressor.

Choice B rationale:

Hyperactive bowel sounds are not typically associated with acute pain. Acute pain is more likely to induce a sympathetic response, which can lead to decreased gastrointestinal motility and hypoactive bowel sounds.

Choice C rationale:

Decreased blood pressure is not a common response to acute pain. Pain often leads to an increase in blood pressure due to the activation of the sympathetic nervous system and the release of stress hormones.

Choice D rationale:

Increased respiratory rate is the anticipated finding in response to acute pain. Acute pain can cause an increase in the sympathetic nervous system activity, leading to a higher respiratory rate as the body prepares for a fight-or-flight response. This increased respiratory rate helps oxygenate the blood and meet the potential increased demand for energy during stress.

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 D

Explanation

Choice A rationale:

Asking the client's closest kin to convince him to stop fasting due to his injuries is not an appropriate action. Respecting the client's religious beliefs and practices is crucial, and attempting to persuade the client to stop fasting would infringe upon their autonomy and cultural values.

Choice B rationale:

Encouraging the client to stop fasting goes against respecting the client's religious observance and autonomy. The nurse should prioritize culturally competent care and support the client in their religious practices, while also ensuring their nutritional needs are met.

Choice C rationale:

Calling dietary to reschedule the client's meals might seem like a reasonable action, but it does not address the client's religious needs or their wound healing process. Ramadan fasting is an important religious practice, and the nurse should find a way to accommodate the client's fasting while also ensuring appropriate nutritional support.

Choice D rationale:

Starting enteral tube feedings if the client refuses to take food orally is the correct action. Beneficence, a principle of ethical nursing care, emphasizes promoting the well-being of the patient. In this case, the nurse should prioritize the client's wound healing by ensuring they receive necessary nutrition through enteral feeding while still respecting their fasting during Ramadan.

A. Contact. B. Droplet. C. Standard. D. Airborne.

Correct Answer is A

Explanation

Choice A rationale:

This choice is correct. Hepatitis B is primarily transmitted through contact with infected blood and bodily fluids. Contact precautions are designed to prevent the spread of infections that are transmitted through direct or indirect contact. These precautions include wearing gloves and gowns when in contact with the client or their environment.

Choice B rationale:

Droplet precautions are not appropriate for hepatitis B. Droplet precautions are used for infections that are spread through respiratory droplets, like coughing or sneezing. Hepatitis B is not primarily transmitted through respiratory droplets.

Choice C rationale:

Standard precautions involve the use of protective barriers such as gloves, gowns, masks, and eye protection to prevent the transmission of infections. While these precautions should always be practiced, they are not specifically tailored to hepatitis B, which has its own set of precautions.

Choice D rationale:

Airborne precautions are used for infections that are spread through small respiratory particles that remain suspended in the air for longer periods. Hepatitis B is not transmitted through airborne routes, so airborne precautions are not necessary.

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 is assessing a client who reports acute pain. The nurse should anticipate which of the following findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an Islamic client who is recovering from a motor vehicle accident. The patient is observing Ramadan, the ninth lunar month. The nurse understands that a good diet is important for the client's wounds to heal. Which action should the nurse take regarding the client's diet?

Correct Answer is D

Explanation

A nurse is admitting a client who has hepatitis

Correct Answer is A

Explanation

A nurse on the Medical-Surgical unit is caring for a patient with a surgical incision that eviscerates. Which actions will the nurse take? (Select all that apply.).

A Medical-Surgical nurse is assessing a client's heart sounds. In which of the following points of auscultation would the nurse hear the S2 sound most clearly?

A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first?

A nurse is assessing a client who reports acute pain. The nurse should anticipate which of the following findings?

A nurse is caring for a client who is scheduled for surgery. Before the client has signed the informed consent form, the client states, "I didn't really understand what that surgeon said." Which of the following actions should the nurse take?

A nurse is caring for a postoperative client who is awake, alert, and oriented. Which of the following methods should the nurse use as part of her pain management interventions to determine the intensity of the client's pain?

A Medical-Surgical nurse is preparing to administer Furosemide to a patient who is having severe heart failure. Which route of administration should the nurse use to provide the fastest and most complete absorption of Furosemide?