A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit.
Which of the following actions should the nurse include in the plan?

Offer the clients many choices regarding care.

Restrict the number of visitors for clients.

Assign different nurses to provide care for clients each day.

Turn on loud music in client care areas.

Answer and Explanation

The Correct Answer is B

This action can help to reduce environmental stressors for clients in an acute care unit by limiting noise, crowding, and potential sources of infection.

Visitors should be allowed according to the client’s preference and condition, but excessive or inappropriate visitors should be discouraged.

Choice A is wrong because offering the clients many choices regarding care can increase their stress and anxiety, especially if they are confused, overwhelmed, or unable to make decisions.

The nurse should respect the client’s autonomy and preferences, but also provide guidance and education to help them make informed choices.

Choice C is wrong because assigning different nurses to provide care for clients each day can reduce the continuity and quality of care, as well as the trust and rapport between the client and the nurse.

The nurse should strive to provide consistent and individualized care for each client and establish a therapeutic relationship.

Choice D is wrong because turning on loud music in client care areas can increase environmental stressors for clients in an acute care unit by creating noise pollution, disrupting sleep, and interfering with communication.

The nurse should maintain a quiet and calm environment for the clients and use music only if it is soothing and requested by the client.

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 A

Explanation

The correct answer is choice A. Use a communication board to interact with the client.

A communication board is a tool that allows the client to point to words, pictures, or symbols that express their needs, feelings, or pain level.

This is an effective way to communicate with a client who speaks a different language than the nurse and is unable to verbalize their pain.

Choice B is wrong because an assistive personnel who speaks the same language as the client is not a qualified interpreter and may not be able to convey the client’s pain accurately or maintain confidentiality.

Choice C is wrong because the FLACC scale is a measurement used to assess pain for children between the ages of 2 months and 7 years or individuals that are unable to communicate their pain.

It is not appropriate for a client who is 6 hours postoperative and can communicate their pain using a communication board.

Choice D is wrong because the FACES pain scale is a self-report measure of pain intensity developed for children.

It uses facial expressions to rate the severity of pain in children from 0-103.

It is not suitable for a client who speaks a different language than the nurse and may not understand the meaning of the faces.

A. Reposition the sensor probe. B. Apply a cooling blanket to the client. C. Place the client in a side-lying position. D. Ambulate the client.

Correct Answer is A

Explanation

The client’s oxygen saturation is 88% on 2 L/min of oxygen via nasal cannula, which is below the normal range of 95% to 100%.

This could indicate that the client is not receiving enough oxygen or that the pulse oximeter is not working properly.

The nurse should first check the sensor probe for any problems, such as poor attachment, nail polish, cold extremities, or motion artifact.

Repositioning the sensor probe may improve the accuracy of the reading and help the nurse determine the next course of action.

Choice B. Apply a cooling blanket to the client is wrong because a cooling blanket is used to lower the body temperature of a client with fever or hyperthermia.

It has no effect on the oxygen saturation level.

Choice C. Place the client in a side-lying position is wrong because a side-lying position may not improve the oxygenation of the client.

A more appropriate position would be a high Fowler’s position, which allows for maximum lung expansion and gas exchange.

Choice D. Ambulate the client is wrong because ambulating the client may worsen the oxygen saturation level if the client has a respiratory condition that causes hypoxemia.

The nurse should assess the client’s respiratory status and oxygen therapy before ambulating the client.

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 assisting in creating a plan to reduce environmental stressors for clients in an acute care unit. Which of the following actions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who speaks a different language than the nurse and is 6 hr postoperative. Which of the following actions should the nurse take to determine the client’s level of pain?

Correct Answer is A

Explanation

A nurse is monitoring a client’s oxygen saturation using a pulse oximeter. The client’s oxygen saturation is 88% on 2 L/min of oxygen via nasal cannula. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client indicates an understanding of this technique?

A nurse in an acute care center is caring for a client who just died. The client’s family requests to perform the postmortem care. Which of the following is an appropriate response for the nurse to make?

A nurse is inserting an indwelling urinary catheter for a female client. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.).

A nurse is reinforcing teaching with a client about the use of a peak flow meter. Which of the following actions should the nurse take first?

A nurse is assisting with scoliosis screenings for students at a public school. Which of the following findings should the nurse recognize as an indication of scoliosis?

A nurse is wearing sterile gloves in preparation for assisting with a client’s sterile procedure. While waiting for the procedure to begin, how should the nurse position her hands?

A nurse is collecting data about a client’s oral care. The client wears dentures and reports having mouth sores. The nurse should identify which of the following oral care practices by the client as a possible cause of the mouth sores?

A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days. Which of the following laboratory findings should the nurse expect?

A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit.
Which of the following actions should the nurse include in the plan?