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 correct answer is Choice B.

Choice A rationale: This choice suggests that the provider will prescribe a different medication regimen. However, this is not necessarily the case. Rifampin is a first-line medication for tuberculosis and its side effects, including the discoloration of body fluids, are well-known and expected. Therefore, it is unlikely that the provider would change the medication regimen solely based on this side effect.

Choice B rationale: This is the correct answer. Rifampin, an antibiotic used to treat tuberculosis, can cause a harmless red-orange discoloration of body fluids, including urine, sweat, tears, and saliva. This is an expected side effect of the medication and does not indicate any harm or toxicity. It is important for the nurse to reassure the client that this is a normal occurrence and does not require any changes to the medication regimen.

Choice C rationale: This choice suggests that the red-orange discoloration of the client’s saliva may indicate possible medication toxicity. However, this is not accurate. While rifampin can have serious side effects, including liver damage and severe gastrointestinal upset, the discoloration of body fluids is not a sign of toxicity. It is a harmless side effect of the medication.

Choice D rationale: This choice suggests that the client will need to increase her fluid intake to resolve the problem. However, increasing fluid intake will not change the discoloration caused by rifampin. The discoloration is a result of the medication itself and is not influenced by the client’s hydration status.

A. Measure the client's blood pressure. B. Prepare the client for temporary pacing. C. Initiate IV fluid therapy for the client. D. Administer atropine to the client.

Correct Answer is A

Explanation

The nurse should measure the client's blood pressure first, as sinus bradycardia can cause hypotension and decreased perfusion to vital organs. The nurse should assess the client's hemodynamic status and symptoms before initiating any interventions that may affect their heart rate or rhythm. The other options may be appropriate depending on the severity of the bradycardia and its underlying cause, but they are not the first priority.

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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 caring for a client who has tuberculosis and is taking rifampin. The client reports that her saliva has turned red-orange in color. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse in an emergency department is caring for a client who has sinus bradycardia. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is preparing to administer daily medications to a client who is undergoing a procedure at 1000 that requires IV contrast dye. Which of the following routine medications to give at 0800 should the nurse withhold?

A nurse is assessing a client who has a serum sodium level of 120 mEq/L. Which of the following findings should the nurse expect?

A nurse is assessing a client who has acute kidney failure. Which of the following findings should the nurse report to the provider?

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A nurse is caring for a client who arrives at the emergency department and reports vomiting and diarrhea for the past 3 days. The client's serum potassium level is 2.8 mEq/L. Which of the following interventions should the nurse implement first?

A nurse is preparing to assist the provider with a thoracentesis for a client who has a left pleural effusion. Which of the following interventions is the priority for the nurse?