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 A
Explanation
Choice A Reason:
Recording the urinary output at the end of each shift is appropriate action. Furosemide is a loop diuretic that increases urine production. Monitoring urinary output is important to assess the effectiveness of the medication and to ensure that the client is not at risk for dehydration or fluid overload. Recording urinary output at the end of each shift provides a comprehensive overview of the client's renal function and fluid balance.
Choice B Reason:
Checking the urine for ketones every 12 hr is inappropriate action. Checking urine for ketones is not a routine assessment for a client with an indwelling urinary catheter and a prescription for furosemide.
Choice C Reason:
Collecting a 24-hr urine specimen to send to the laboratory is inappropriate. Collecting a 24-hour urine specimen is a more extensive test and is not typically needed for routine monitoring of a client on furosemide.
Choice D Reason:
Measuring the specific gravity of the urine during each shift is incorrect. While monitoring specific gravity can provide information about the concentration of urine, it is not usually required for routine monitoring in this specific situation. Monitoring urinary output is a more practical and clinically relevant approach.
Correct Answer is C
Explanation
A. A family member is napping in the client's room.
This situation, while not ideal, doesn't involve harm or potential harm to a client, staff, or visitor. It may be addressed through communication and policy reminders but may not require an incident report.
B. A client refuses to eat at mealtime.
Client refusal to eat, while concerning, is not an unexpected or unusual event. It is a common aspect of care, and incident reports are not typically used for such situations.
C. A client's bed alarm is malfunctioning.
This situation involves a malfunction in equipment designed to ensure client safety. It has the potential to compromise the safety of the client and may require an incident report to document the issue and address it appropriately.
D. An assistive personnel is late for the upcoming shift.
Lateness may be an issue that needs addressing, but it's not typically considered an incident requiring a formal incident report. This situation may be addressed through workplace policies and communication.
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