The nurse is assessing a client experiencing acute pain.
What assessments should validate the client with acute pain? Select all that apply.

This is the proper way to obtain a throat culture, which is a test to look for infections in the back of the throat.

Some possible explanations for the other choices are:

Choice B is wrong because there is no need to avoid eating or drinking after a throat culture.

The swab does not interfere with the normal function of the mouth or throat.

Choice C is wrong because coughing while swabbing the throat could contaminate the sample or cause discomfort to the client. The swab should be gently passed along the back area of the throat and tonsils.

Choice D is wrong because swabbing only the anterior tongue would not collect enough cells from the infected area. The swab should reach the back of the throat where bacteria or fungi may grow.

This is because the nurse should first ensure that help is on the way before performing any other actions on an unconscious and unresponsive client. Calling for assistance may also alert someone who can bring an automated external defibrillator (AED) if needed.

Choice B is wrong because giving 2 rescue breaths is part of CPR, which should only be done after checking for a pulse and finding none or a weak one.

Giving rescue breaths to a client who has a pulse may cause harm.

Choice C is wrong because checking for apical pulse is not the most reliable way to assess circulation in an emergency situation. The nurse should check for a carotid pulse instead, which is easier to locate and more indicative of blood flow to the brain.

Choice D is wrong because beginning chest compressions is also part of CPR, which should only be done after calling for assistance and checking for a pulse and finding none or a weak one.

Chest compressions may cause harm to a client who has a pulse.