A nurse is assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain?

A client who has peritonitis reports generalized abdominal pain.

A client who has angina reports substernal chest pain.

A client who has pancreatitis reports pain in the left shoulder.

A client who is postoperative reports incisional pain.

Answer and Explanation

The Correct Answer is C

Referred pain is pain that is felt in a location different from its source due to shared nerve pathways or central nervous system processing. A client who has pancreatitis may experience pain in the left shoulder due to irritation of the diaphragm by pancreatic enzymes or inflammation. This pain is referred from the abdominal cavity to the shoulder through the phrenic nerve.

A client who has peritonitis reports generalized abdominal pain that corresponds to the site of inflammation and infection in the peritoneum. A client who has angina reports substernal chest pain that reflects the ischemia and hypoxia of the myocardium. A client who is postoperative reports incisional pain that is caused by tissue damage and inflammation at the surgical site.

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Correct Answer is B

Explanation

The client should expect less than 25 mL of secretions per day in the drainage devices before they are removed, usually within 7 to 10 days after surgery. This indicates that the wound is healing and there is no excessive fluid accumulation in the surgical site. The other statements are incorrect and indicate a need for further teaching. The client should not wait 2 months before additional saline can be added to the breast expander, as this may delay the reconstruction process and increase the risk of infection or contracture.

The client should keep the left arm elevated on a pillow and avoid flexing it at the elbow, as this may impair lymphatic drainage and cause edema or pain. The client should perform gentle range-of-motion exercises with the left arm and avoid lifting heavy objects such as a 15-pound weight, as this may strain the incision or cause bleeding.

A. Hang the drainage bag below the client's abdomen. B. Use clean technique to access the catheter. C. Place the client in high-Fowler's position. D. Chill the dialysate before administration.

Correct Answer is A

Explanation

The nurse should hang the drainage bag below the level of the client's abdomen to facilitate gravity drainage of fluid and waste products from the peritoneal cavity. The other options are incorrect because they may cause discomfort, infection, or inadequate dialysis.

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A nurse is assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is preparing to administer peritoneal dialysis to a client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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