An older adult client grimaces and demonstrates guarding behavior, but denies experiencing pain when asked by the nurse to rate the pain on a numeric scale. Which action should the nurse take next?

Ask the client to describe how they are feeling.

Administer a PRN dose of a prescribed analgesic.

Document that the client denies pain in the nurse's notes.

Confront the client about inconsistent behavior and response.

Answer and Explanation

The Correct Answer is A

A.   Asking the client to describe their feelings provides an opportunity to explore their symptoms in more detail, which might help in understanding their pain better. This approach respects the client's experience and opens a dialogue to assess their discomfort more accurately, especially if they are not expressing it verbally or are having difficulty quantifying it.
B.   Administering medication without further assessment might be premature. The client's denial of pain and the presence of grimacing and guarding behavior suggest that there may be underlying discomfort, but it's crucial to assess the situation more thoroughly before administering medication.
C.   While documenting the client’s verbal denial of pain is important, it should not be the only action taken. The client's non-verbal cues such as grimacing and guarding behavior suggest that they might be experiencing pain despite their verbal denial.
D.   Confronting the client could be perceived as accusatory and might make them feel defensive or uncomfortable. It's important to approach the situation with empathy and understanding rather than confrontation.

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Correct Answer is C

Explanation

A. While it’s important to inform the charge nurse of any issues with the collection process, this action alone does not address the core problem of the collection being compromised. The charge nurse may offer guidance or assist in deciding the next steps, but the primary focus should be on correcting the collection process to ensure accurate results.
B. Notifying the healthcare provider can be important, especially if the results of the 24-hour urine collection are critical to the client’s diagnosis or treatment plan. However, it is usually more efficient to first address the issue of the collection itself and then inform the healthcare provider about the results of these corrective actions.
C. This is the most appropriate action when a mistake occurs in the collection process, such as flushing a voided sample. The integrity of the collection is compromised, and starting a new 24-hour collection period ensures that all samples are accounted for and that the results will be accurate.
D. Adding extra time to the urine collection period does not compensate for the missed sample. The accuracy of the collection depends on having all urine samples from the full 24-hour period.

A. Measure body temperature. B. Administer PRN oxygen. C. Send for chest x-ray. D. Obtain sputum for culture.

Correct Answer is B

Explanation

A. Measuring body temperature is important in assessing the client’s overall condition and identifying a fever, which is common in pneumonia. However, while it provides useful information about the client's status, it is not the most urgent action compared to interventions that could immediately impact the client’s respiratory function or confirm the diagnosis.
B. Administering PRN (as needed) oxygen is crucial if the client shows signs of hypoxia or difficulty breathing. If the client's face appears cyanotic or if they are experiencing respiratory distress, this action should be prioritized to ensure adequate oxygenation.
C. A chest x-ray is essential for diagnosing pneumonia and assessing the extent of lung involvement. However, while it is critical for diagnosis, addressing immediate respiratory needs and symptoms takes precedence.
D. Obtaining sputum for culture is important for identifying the causative organism and guiding antibiotic therapy. However, this action is less urgent than ensuring the client’s immediate respiratory needs are met and confirming the diagnosis through imaging.

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An older adult client grimaces and demonstrates guarding behavior, but denies experiencing pain when asked by the nurse to rate the pain on a numeric scale. Which action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client started a 24-hour urine collection several hours ago. The client tells the nurse that the last voiding was accidentally flushed instead of saved in the container. Which intervention should the nurse initiate?

Correct Answer is C

Explanation

A client is admitted with possible pneumonia. When entering the room, the nurse observes the client's face as seen in the picture. Which prescription should the nurse implement first?

Correct Answer is B

Explanation

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