For the client who reports pain, the nurse should consider the following as the most reliable indicator of pain:

Severity of the condition

Vital signs

Nonverbal behavior

Self-report of pain

Answer and Explanation

The Correct Answer is D

Choice A reason: The severity of the condition may not always correlate with the level of pain experienced by the client. Pain is a subjective experience, and two individuals with the same condition may report different levels of pain.

Choice B reason: Vital signs can be indicators of pain but are not always reliable. For example, some clients may exhibit increased heart rate or blood pressure when in pain, while others may not show significant changes in vital signs despite severe pain.

Choice C reason: Nonverbal behavior can be an indicator of pain, especially in clients who are unable to communicate verbally. However, it is still considered less reliable than self-report because it is subject to interpretation by the observer.

Choice D reason: Self-report of pain is considered the most reliable indicator of a patient's pain experience. It is a direct expression of the client's experience and should be the primary source of assessment whenever possible.

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Correct Answer is C

Explanation

Choice A reason: While providing a newborn's first bath, there is minimal risk of exposure to infectious fluids that would necessitate eye protection. However, standard precautions should always be followed.

Choice B reason: When giving personal care to an infant who is HIV-positive, standard precautions should be followed, which includes wearing gloves. Eye protection is not typically required unless there is a risk of splashing bodily fluids.

Choice C reason: Suctioning secretions from a child's newly placed tracheostomy tube requires eye protection because there is a high risk of secretions being expelled forcefully, which could contact the mucous membranes of the eyes.

Choice D reason: Withdrawing cord blood from a neonate generally does not require eye protection unless there is a risk of blood splatter. Standard precautions, including the use of gloves, should be sufficient.

Choice E reason: Transporting a cerebrospinal fluid specimen to the laboratory does not require the nurse to wear eye protection. However, the nurse should ensure that the specimen is sealed properly to prevent any leaks.

A. Wrapping the cuff too loosely around the client's arm B. Measuring blood pressure right after the client's mealtime C. Positioning the client's arm above heart level D. Deflating the cuff too slowly

Correct Answer is C

Explanation

The correct answer is: c. Positioning the client’s arm above heart level.

Choice A: Wrapping the cuff too loosely around the client’s arm

Wrapping the cuff too loosely can lead to an inaccurately high blood pressure reading, not a low one. A loose cuff does not compress the artery properly, causing the device to overestimate the pressure needed to occlude the artery.

Choice B: Measuring blood pressure right after the client’s mealtime

Measuring blood pressure right after a meal can cause a slight increase in blood pressure due to the body’s metabolic response to digestion. This is not a common cause of a low blood pressure reading.

Choice C: Positioning the client’s arm above heart level

Positioning the client’s arm above heart level can lead to an inaccurately low blood pressure reading. When the arm is elevated, the hydrostatic pressure decreases, resulting in a lower reading. This is a well-known source of error in blood pressure measurement.

Choice D: Deflating the cuff too slowly

Deflating the cuff too slowly can cause venous congestion, which may lead to an inaccurately high reading rather than a low one. The standard deflation rate is 2-3 mm Hg per second to ensure accurate measurement.

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For the client who reports pain, the nurse should consider the following as the most reliable indicator of pain:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients. For which of the following tasks should the nurse plan to wear protective eye equipment?

Correct Answer is C

Explanation

When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?

Correct Answer is C

Explanation

Choice A: Wrapping the cuff too loosely around the client’s arm

Choice B: Measuring blood pressure right after the client’s mealtime

Choice C: Positioning the client’s arm above heart level

Choice D: Deflating the cuff too slowly

A nurse is caring for a client who has pneumonia. The client's oxygen saturation is 88%. Which of the following actions should the nurse take first?

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

A nurse caring for a client who requires isolation has just finished a care procedure. Which of the following pieces of personal protective equipment (PPE) should the nurse remove last?

A nurse has accidentally punctured his finger with a needle he used to give an IM injection to a client. Which of the following actions should the nurse take?

A nurse inserts an indwelling urinary catheter for a client who is preoperative. Three days later, the client develops a urinary tract infection. The nurse should identify that the client has which of the following types of infections?

A nurse is reinforcing teaching about promoting rest and sleep with a client who reports insomnia. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

A nurse is monitoring a postoperative client who is unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client is experiencing pain? (Select all that apply)

A nurse is preparing an in-service presentation about preventing healthcare-associated infections (HAIs). The nurse should include which of the following as a common cause of these infections?