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

Restlessness.

Dilated pupils.

Constricted pupils.

Diaphoretic skin.

Increased respirations.

Decreased respirations

Answer and Explanation

Correct Answer : A,D,E

These choices validate the client with acute pain because they are signs of a sympathetic nervous system response to pain. Acute pain is a sudden and usually sharp sensation that indicates tissue damage or injury.

Choice B is wrong because dilated pupils are not a sign of acute pain. Pupils may dilate in response to fear, excitement, or drugs.

Choice C is wrong because constricted pupils are not a sign of acute pain. Pupils may constrict in response to bright light, drugs, or brain damage.

Choice F is wrong because decreased respirations are not a sign of acute pain. Respirations may decrease in response to relaxation, drugs, or respiratory depression.

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Correct Answer is B

Explanation

To find the rate of the pump in ml/hour, you need to first convert the client’s weight from pounds to kilograms. You can do this by dividing the weight by 2.2046 or multiplying it by 0.454.

For example:

297 lbs / 2.2046 = 134.72 kg or 297 lbs x 0.454 = 134.72 kg

Then, you need to multiply the client’s weight in kilograms by the ordered dose in units/kg/hour to get the total units per hour.

For example:

134.72 kg x 12 units/kg/hour = 1616.64 units/hour

Next, you need to set up a proportion to find the rate of the pump in ml/hour using the supplied medication concentration.

For example:

25,000 units / 500 ml = 1616.64 units / X ml Cross-multiply and solve for X:

25,000 x X = 808320 X = 808320 / 25000 X = 32.33 ml/hour

Finally, you need to round your answer to the nearest tenth of a ml/hour as per the medication administration guidelines.

For example:

32.33 ml/hour ≈ 32.3 ml/hour

Therefore, the rate of the pump is 32.3 ml/hour.

Choice A is wrong because it uses a different conversion factor for pounds to kilograms (1 lb = 0.5 kg) which is not accurate.

Choice C is wrong because it uses a different ordered dose (10 units/kg/hour) which is not what the provider has written.

Choice D is wrong because it uses a different supplied medication concentration (20,000 units in 500 ml) which is not what is available.

A. Eyes, ears, lips, and scalp. B. Palms, soles and nails. C. Head, neck and trunk. D. Lower legs and back.

Correct Answer is B

Explanation

Palms, soles and nails.

Melanoma is a type of skin cancer that can develop in any color skin, including dark or black skin.

However, melanoma on dark skin is not related to sun exposure and can start in places that get little sun. That includes the palms of your hands, soles of your feet, nails, and inside your mouth, anal, and genital areas.

Choice A is wrong because eyes, ears, lips, and scalp are not common areas for melanoma in people of color.

Choice C is wrong because head, neck and trunk are more likely to be affected by sun exposure and other types of skin cancer than melanoma in people of color.

Choice D is wrong because lower legs and back are also more exposed to sun and other types of skin cancer than melanoma in people of color.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A provider has written an order for a medication drip to be started at 12 units/kg/hour. Your client weighs 297 Ibs. The medication is supplied as 25,000 units in 500 ml. At what rate would you set your pump?

Correct Answer is B

Explanation

Which areas should the nurse teach a dark-skinned client to inspect regularly for skin cancer like melanoma?

Correct Answer is B

Explanation

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