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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A Reason:

"I should advance my crutches up the step ahead of my unaffected leg" This statement demonstrates an understanding of the correct technique for ascending stairs with crutches. The client should advance the crutches onto the step first, followed by the unaffected leg.

Choice B Reason:

"I should keep my elbows straight when I am walking with my crutches": It is recommended to maintain a slight bend in the elbows to absorb shock and provide stability during crutch walking.

Choice C Reason:

"I will support my weight on the hand grips of the crutches": This is not an accurate statement. Weight should be supported through the hands and arms, not just the hand grips.

Choice D Reason:

"When I'm walking around my house with my crutches, it's okay to take my shoes off": Walking with crutches while barefoot can increase the risk of slipping and falling. It is generally recommended to wear supportive footwear.

A. Discard the vial with the remaining medication in the sharp container. B. Have another nurse witness the disposal of the remaining medication. C. Draw up the remaining 1 mg in a syringe and label it with the contents, date, and time. D. Store the vial in the client's medication drawer for future use.

Correct Answer is C

Explanation

Choice A Reason:

Discarding the vial with the remaining medication in the sharp container is inappropriate. This would result in unnecessary waste of the medication and could lead to increased healthcare costs.

Choice B Reason:

Having another nurse witness the disposal of the remaining medication is inappropriate. Witnessing the disposal is typically required for controlled substances, but in this situation, it's more appropriate to use the remaining medication with appropriate documentation.

Choice C Reason:

Drawing up the remaining 1 mg in a syringe and label it with the contents, date, and time is appropriate. This approach minimizes medication wastage and allows for appropriate documentation of the extra dose drawn up. However, it is crucial to label the syringe clearly with the contents, date, and time to avoid any potential errors or confusion. This labeled syringe can then be used for subsequent doses, as long as it remains within the medication's expiration period and adheres to institutional policies.

Choice D Reason:

Storing the vial in the client's medication drawer for future use is inappropriate. Keeping the vial for future use without appropriate documentation is not recommended, as it may lead to medication errors or confusion.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing discharge instructions with a client who is walking with crutches. Which of the following statements by the client indicates an understanding of the instructions?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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