A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?

Use the diaphragm of the stethoscope to listen to the apical pulsations

Count the apical pulsations for a full minute

Press the stethoscope firmly against the client's skin

Check the apical pulse with a Doppler device

Answer and Explanation

The Correct Answer is B

Choice A reason: The diaphragm of the stethoscope is used for high-pitched sounds such as breath sounds, bowel, and normal heart sounds. For the apical pulse, which involves listening to the heart's sounds, the bell of the stethoscope is often recommended, especially for lower-pitched sounds like murmurs.

Choice B reason: Counting the apical pulsations for a full minute is the correct action when assessing the apical pulse, particularly for clients on cardiovascular medications. This ensures accuracy in detecting any irregularities or changes in the heart rate that could be affected by the medications.

Choice C reason: The stethoscope should be placed gently against the client's skin. Pressing too firmly can distort the heart sounds, making it difficult to accurately assess the apical pulse.

Choice D reason: A Doppler device is not typically used for routine assessment of the apical pulse. It is more commonly used when pulses are difficult to palpate or auscultate, such as in cases of peripheral arterial disease.

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Correct Answer is D

Explanation

Choice A reason: Protective precautions are used to shield immunocompromised patients from infections, not typically for patients with meningococcal pneumonia.

Choice B reason: Contact precautions are used for infections that are spread by direct contact with the patient or the patient's environment. Meningococcal pneumonia is not primarily spread this way.

Choice C reason: Airborne precautions are for diseases that are spread through the air over long distances, such as tuberculosis. Meningococcal pneumonia is not spread in this manner.

Choice D reason: Droplet precautions are recommended for meningococcal pneumonia. This infection can be spread through droplets from the respiratory tract when the infected person coughs or sneezes. Therefore, droplet precautions, including the use of masks, are necessary to prevent the spread of this infection.

A. Expect the client to express his pain both verbally and nonverbally. B. Administer opioids with caution because they will eventually lead to addiction. C. To achieve fast-acting pain relief, administer analgesics orally. D. Use a scale from 0 to 10 to monitor the severity of the client's pain. E. Observe the clients pain expression

Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason: Expecting the client to express pain both verbally and nonverbally is important in postoperative care. Pain expression is subjective and can vary greatly among individuals. Some clients may verbalize their discomfort, while others may exhibit nonverbal cues such as grimacing, restlessness, or guarding the affected area. It is crucial for nurses to be attentive to all forms of pain expression to assess and manage the client's pain effectively.

Choice B reason: Administering opioids with caution is a standard practice due to the risk of addiction; however, the statement that they will eventually lead to addiction is misleading. Opioids, when used appropriately and under medical supervision, are an effective component of postoperative pain management. The risk of addiction is present but can be mitigated through careful monitoring, patient education, and using the lowest effective dose for the shortest duration necessary.

Choice C reason: Administering analgesics orally for fast-acting pain relief is a common practice, especially when immediate onset is not required. Oral administration is non-invasive and convenient, but it is not the fastest method for pain relief compared to intravenous administration. The choice of analgesic and the route of administration should be based on the client's pain level, type of surgery, and individual needs.

Choice D reason: Using a pain scale from 0 to 10 is an effective way to monitor the severity of the client's pain. This method provides a quantifiable measure of pain intensity, allowing for consistent assessment and facilitating communication between the client and healthcare providers. It helps in evaluating the effectiveness of pain management interventions and in making necessary adjustments to the pain management plan.

Choice E reason: Considering the client's individual expression of pain is essential in postoperative care. Pain is a personal experience, and what may be tolerable for one person could be unbearable for another. Factors such as cultural background, previous pain experiences, psychological state, and the presence of comorbidities can influence pain perception. Tailoring pain management strategies to the individual's needs and preferences is key to effective pain control.

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A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the admission of a client who has meningococcal pneumonia. Which of the following isolation precautions should the nurse initiate?

Correct Answer is D

Explanation

A nurse is caring for a client who is postoperative. When helping to manage the client's pain, which of the following should apply? (Select all that apply)

Correct Answer is ["A","C","D","E"]

Explanation

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