After reviewing the admission assessment of a client with chronic pain, which intervention(s) should the nurse include in this client's plan of care? (Select all that apply.)

Provide comfort measures such as topical warm application and tactile massage.

Assist the client to ambulate as much as possible during waking hours.

Determine client's subjective measure of pain using a numerical pain scale.

Encourage increased fluid intake and measure urinary output every 8 hours.

Implement a 24-hour schedule of routine administration of prescribed analgesic.

Answer and Explanation

Correct Answer : A,C,E

Choice A Reason: This is correct because providing comfort measures such as topical warm application and tactile massage can help reduce pain perception and promote relaxation by stimulating non-painful sensory receptors.

Choice B Reason: This is incorrect because assisting the client to ambulate as much as possible during waking hours can increase pain intensity and fatigue by aggravating inflamed or injured tissues. The nurse should encourage moderate physical activity within the client's tolerance level.

Choice C Reason: This is correct because determining client's subjective measure of pain using a numerical pain scale can help assess pain severity and effectiveness of pain management interventions. Pain is a subjective experience that varies among individuals.

Choice D Reason: This is incorrect because encouraging increased fluid intake and measuring urinary output every 8 hours are not directly related to pain management. These interventions are more relevant for clients with fluid imbalance or renal impairment.

Choice E Reason: This is correct because implementing a 24-hour schedule of routine administration of prescribed analgesic can help maintain a steady level of analgesia and prevent breakthrough pain. Chronic pain requires continuous treatment rather than on-demand administration.

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Correct Answer is D

Explanation

Choice A Reason: Massaging the injection site can cause bruising and bleeding, and is not recommended for subcutaneous heparin injections.

Choice B Reason: Rotating injections between different body sites can increase the risk of hematoma formation and skin irritation, and is not advised for subcutaneous heparin injections.

Choice C Reason: Expelling the air in the prefilled syringe can result in a loss of medication dose, and is not necessary for subcutaneous heparin injections.

Choice D Reason: Injecting in the abdominal area at least 2 inches from the umbilicus is the correct technique for subcutaneous heparin injections, as it reduces the risk of injury to blood vessels and nerves, and ensures consistent absorption of the medication.

A. Instill 50 mL of normal saline solution into the tube and clamp the tube for one hour. B. Turn the suction off while allowing the client to rinse his mouth with cool water. C. Provide oral sponge toothettes so the client can cleanse and moisten his mouth. D. Teach the client that the oral mucosa must remain dry to prevent aspiration.

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because instilling normal saline solution into the nasogastric tube can cause fluid overload, electrolyte imbalance, or aspiration. Clamping the tube for one hour can also increase the risk of aspiration and gastric distension.

Choice B Reason: This is incorrect because turning the suction off can cause gastric distension and discomfort. Rinsing the mouth with cool water can also increase the risk of aspiration if the client swallows some of the water.

Choice C Reason: This is correct because oral sponge toothettes are soft and gentle on the oral mucosa and can help moisten and cleanse the mouth without causing irritation or aspiration.

Choice D Reason: This is incorrect because teaching the client that the oral mucosa must remain dry is false and can lead to further dryness, cracking, bleeding, and infection. The oral mucosa should be kept moist and clean to prevent these complications.

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After reviewing the admission assessment of a client with chronic pain, which intervention(s) should the nurse include in this client's plan of care? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a client how to self-administer low-molecular-weight heparin subcutaneously. Which instruction should the nurse include?

Correct Answer is D

Explanation

A male client with a nasogastric tube connected to low intermittent suction tells the nurse that his mouth is very dry. Which action should the nurse implement?

Correct Answer is C

Explanation

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