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 D

Explanation

Choice A reason: Inspection should be performed first to observe for any visible abnormalities, distention, or movements that could indicate underlying conditions.

Choice B reason: Percussion is used after auscultation to assess the presence of fluid, gas, and to estimate the size of the organs within the abdomen.

Choice C reason: Palpation is typically performed last because it can alter the natural state of the abdomen, potentially causing discomfort and affecting the bowel sounds that are assessed during auscultation.

Choice D reason: Auscultation should be performed before palpation and percussion to avoid altering bowel sounds. It allows the nurse to listen to the natural state of bowel motility and vascular sounds without interference.

A. Droplet B. Protective environment C. Airborne D. Contact

Correct Answer is B

Explanation

Choice A reason: Droplet precautions are necessary when dealing with infectious agents that are spread through large droplets expelled during coughing, sneezing, or talking. However, leukemia itself is not an infectious disease but a type of cancer affecting the blood and bone marrow. Therefore, droplet precautions are not typically required for leukemia patients unless they have a concurrent infection that warrants such measures.

Choice B reason: A protective environment refers to room designs that minimize the risk of infection in immunocompromised patients, such as those with leukemia. This includes HEPA filtration, positive air pressure rooms, and rigorous infection control practices. Given that patients with leukemia have compromised immune systems, a protective environment is crucial to protect them from infections, which can be life-threatening due to their reduced ability to fight off diseases.

Choice C reason: Airborne precautions are used for diseases that are transmitted through tiny droplets that remain suspended in the air and can be inhaled by others. Diseases like tuberculosis, measles, and chickenpox require airborne precautions. Leukemia does not require airborne precautions unless the patient has a coexisting airborne infection.

Choice D reason: Contact precautions are used for infections that are spread by direct contact with the patient or the patient's environment. While leukemia patients may be more susceptible to infections due to their compromised immune systems, contact precautions are not specifically required for leukemia itself but may be necessary if the patient has a concurrent contact-transmissible infection.

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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

When assessing a client's abdomen, particularly for "stomach pain," the nurse should:

Correct Answer is D

Explanation

A nurse is assisting with the admission of a client who has leukemia. Which of the following transmission precautions should the nurse implement?

Correct Answer is B

Explanation

A nurse is collecting data from a client who has insomnia. The nurse should identify that which of the following is likely to disrupt sleep?

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?

For the client with obstructive sleep apnea (OSA), the nurse should expect the following findings:

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 is caring for a client who is postoperative. Which of the following actions should the nurse take to help prevent an incisional infection?

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 is caring for a client who was placed on isolation precautions for active pulmonary tuberculosis (TB). Which of the following actions should the nurse plan to take? (Select all that apply.)

A nurse is collecting data about a client's circulatory system. Which of the following pulse sites should the nurse avoid checking bilaterally at the same time?