A nurse is assessing a newborn who had a circumcision 2 hr ago. Which of the following findings should the nurse identify as an indication that the newborn has acute pain?

Decrease in heart rate

Increase in vagal nerve tone

Decrease in respiratory rate

Increase in muscle tone

Answer and Explanation

The Correct Answer is D

A. Decrease in heart rate: Acute pain typically causes an increase in heart rate, not a decrease.
B. Increase in vagal nerve tone: An increase in vagal nerve tone can actually result in a decreased heart rate and is not a direct indicator of acute pain.
C. Decrease in respiratory rate: Acute pain usually causes an increase in respiratory rate, not a decrease.
D. Increase in muscle tone: This is correct. An increase in muscle tone can indicate acute pain as the body tenses in response to 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 B

Explanation

A. Cleanse the urethral meatus. This step occurs after preparing the sterile field and donning sterile gloves.
B. Apply sterile gloves. This is correct. The first step in the standardized procedure is to apply sterile gloves to maintain aseptic technique throughout the catheter insertion process.
C. Attach the pre-filled syringe to the inflation bulb. This step is part of the preparation but comes after the sterile gloves are applied.
D. Saturate the cotton balls with antiseptic. This step occurs after donning sterile gloves.

A. Install a bed exit sensor pad at the foot of the client's bed. B. Encourage the client to ambulate in compression stockings. C. Raise all four side rails for the client at bedtime. D. Place a raised toilet seat in the client's bathroom.

Correct Answer is D

Explanation

A. Install a bed exit sensor pad at the foot of the client's bed. While a bed exit sensor pad can be useful, it is typically placed on the mattress near the client's hips or lower back, not at the foot of the bed. This placement ensures it detects movement when the client tries to get up, thereby alerting staff to provide assistance.
B. Encourage the client to ambulate in compression stockings. Compression stockings can help with circulation but do not directly address fall prevention. Additionally, they can be slippery on some surfaces, potentially increasing the risk of falls if proper footwear is not used.
C. Raise all four side rails for the client at bedtime. Raising all four side rails is considered a form of restraint and can increase the risk of injury if the client attempts to climb over them. It can also limit the client’s ability to get out of bed independently and safely.
D. Place a raised toilet seat in the client's bathroom. This intervention is appropriate for fall prevention. A raised toilet seat can help clients with mobility issues by making it easier to sit down and stand up, thereby reducing the risk of falls in the bathroom, which is a common site for falls.

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 newborn who had a circumcision 2 hr ago. Which of the following findings should the nurse identify as an indication that the newborn has acute pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following steps of the standardized procedure should the nurse plan to take first?

Correct Answer is B

Explanation

A nurse is developing a plan of care for a client who is at risk for falls. Which of the following interventions should the nurse include?

Correct Answer is D

Explanation

A nurse is caring for a female client who practices Islam. Which of the following client preferences should the nurse expect when providing care?

A nurse is caring for a client who has an indwelling urinary catheter in place to manage occasional urinary incontinence. When following evidence- based practice, which of the following actions should the nurse take first?

A nurse is caring for a client who has diarrhea. Which of the following medications should the nurse expect the provider to prescribe?

A nurse is collecting a culture specimen from a client's nonhealing wound. Which of the following actions should the nurse take first?

A nurse is teaching a male client about testicular self-examinations. Which of the following client responses indicates an understanding of the teaching?

A nurse is preparing to perform preoperative care for a client who does not speak the same language as the nurse. The client has signed the informed consent form, but is refusing preoperative care. Which of the following actions should the nurse take?

A nurse manager is developing an in-service about The Joint Commission's National Patient Safety Goals for a group of surgical nurses. Which of the following information regarding Universal Protocol should the nurse include in the in-service?

A nurse on an acute care unit receives a request from a client's provider to fax a laboratory report to his office. Which of the following actions should the nurse take?