An accident arrives at the emergency department (ED) with severe right lower quadrant abdominal pain.
To assess the intensity of the client's pain, which approach should the nurse use?

Ask the client to describe the pain.

Provide a numeric pain scale.

Identify effective pain relief measures.

Observe body language and movement.

Answer and Explanation

The Correct Answer is B

The assessment of pain intensity by a validated pain scale is a critical initial step, and a patient’s self-reporting is widely considered as the key to effective pain management 1.

According to good practice guidelines, clinicians must accept a patient’s statement, regardless of their own opinions 1.

Choice A is not the answer because asking the client to describe the pain does not provide an objective measure of pain intensity 1.

Choice C is not the answer because identifying effective pain relief measures does not assess the intensity of the client’s pain 1.

Choice D is not the answer because observing body language and movement does not provide an objective measure of pain intensity 1.

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Correct Answer is A

Explanation

Inject in abdominal area at least 2 inches from the umbilicus.

When administering subcutaneous heparin injections, it is important to choose an injection site on either your tummy or outer areas of your left or right thigh.

Your tummy is usually best as the injection site and it is important that you change the site each time 1.

The heparin needs to go into the fat layer under the skin 2.

Choice B is incorrect because injections should not be rotated between the abdomen and gluteal areas.

Choice C is incorrect because massaging the injection site is not recommended.

Choice D is incorrect because air bubbles in a pre-filled syringe should not be expelled prior to injection 2.

Correct Answer is ["1"]

Explanation

The nurse should instruct the client to take 1 tablespoon within each dose.

Since the prescription is for 30 mg of dextromethorphan and the bottle is labeled “Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL”, the client should take 15 mL of the suspension per dose.

Since there are 15 mL in 1 tablespoon, the client should take 1 tablespoon of the suspension per dose.

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An accident arrives at the emergency department (ED) with severe right lower quadrant abdominal pain. To assess the intensity of the client's pain, which approach should the nurse use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a client how to self-administer subcutaneous heparin injections. Which instruction should the nurse include?

Correct Answer is A

Explanation

A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours as needed for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL". How many tablespoons should the nurse instruct the client to take within each dose? (Enter numerical value only).

Correct Answer is ["1"]

Explanation

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An accident arrives at the emergency department (ED) with severe right lower quadrant abdominal pain.
To assess the intensity of the client's pain, which approach should the nurse use?