A nurse is caring for a who speaks a different language than the nurse and is 6 hr postoperative. Which of the following actions should the worse take to determine the client's level of pain?
Use the FACES pain scale to gauge the client's level of pain.
Use a communication board to interact with the client.
Use the Face, Legs, Activity, Cry, Consolability (FLACC) scale to measure the client's pain level.
Ask an assistive personnel who speaks the same language as the client to interpret.
The Correct Answer is C
Choice A Reason:
Using the FACES pain scale to gauge the client's level of pain is appropriate. This scale relies on the client's ability to understand and communicate using a specific language, which might not be possible if there is a language barrier.
Choice B Reason:
Using a communication board to interact with the client is inappropriate. While communication boards can be helpful, they might not effectively gauge the client's level of pain, especially if the client's primary language isn't available on the board.
Choice C Reason:
Using the Face, Legs, Activity, Cry, Consolability (FLACC) scale to measure the client's pain level is appropriate. The FLACC scale is a pain assessment tool that evaluates pain in nonverbal patients or those who can't communicate effectively. It assesses facial expressions, leg movement, activity level, crying, and consolability to determine the level of pain the patient is experiencing.
Choice D Reason:
Asking an assistive personnel who speaks the same language as the client to interpret is inappropriate. Relying on an interpreter, even if they speak the same language as the client, might not be the best approach for pain assessment, as nuances related to pain expression and interpretation might be better captured through a standardized pain assessment tool like the FLACC scale.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Turning the hearing aid off for 5 minutes is inappropriate action. Turning the hearing aid off may temporarily stop the whistling sound, but it doesn't address the underlying issue. Additionally, it would leave the client without the ability to hear during that time.
Choice B Reason:
Cleaning the hearing aid with isopropyl alcohol is inappropriate action. While cleaning the hearing aid is important for maintenance, using isopropyl alcohol may not directly address the issue of whistling. It's a good practice for routine cleaning, but it may not be the solution in this specific case.
Choice C Reason:
Decreasing the volume on the hearing aid is appropriate action. Whistling sounds, also known as feedback, can occur when the volume on the hearing aid is too high. Decreasing the volume is a reasonable first step to address this issue.
Choice D Reason:
Soaking the hearing aid in warm water is inappropriate. Soaking a hearing aid in warm water is not recommended, as moisture can damage the internal components of the hearing aid. It's essential to keep hearing aids dry to ensure proper functioning.
Correct Answer is C
Explanation
Choice A Reason:
Adding diluent to the medication is not appropriate for ampules. Ampules typically contain a single-dose of medication in a liquid form.
Choice B Reason:
The ampule should be cleansed before opening to remove any potential contaminants. Once the ampule is opened, the inside of the ampule and the medication should be considered sterile, so there is no need to cleanse the tip after opening.
Choice C Reason:
A filter needle is used to prevent any glass particles from entering the syringe when drawing medication from an ampule, as ampules are made of glass that can sometimes break and leave shards.
Choice D Reason:
Injecting air into the ampule is not necessary. Ampules are designed to allow for the withdrawal of medication without the need to inject air.
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