The nurse is assessing a client who is having pain in the right upper abdominal area. To assess the quality of the client’s abdominal pain, which approach should the nurse use?

Identify effective pain relief measures.

Ask the client to describe the pain.

Provide a numeric pain scale.

Observe body language and movement.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Identifying effective pain relief measures is important, but it does not directly assess the quality of the pain. This approach focuses on management rather than understanding the pain’s characteristics.

Choice B rationale

Asking the client to describe the pain is the most direct way to assess its quality. This allows the nurse to gather detailed information about the pain’s nature, intensity, and characteristics, which is crucial for accurate diagnosis and treatment.

Choice C rationale

Providing a numeric pain scale helps quantify the pain’s intensity but does not provide qualitative details about the pain’s nature. It is useful for monitoring pain levels over time but not for initial assessment.

Choice D rationale

Observing body language and movement can give clues about pain but is subjective and less reliable than directly asking the client. It should be used as a supplementary method rather than the primary approach.

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Correct Answer is A

Explanation

Choice A rationale

Placing a client in restraints without having a healthcare provider’s order is a violation of patient rights and safety protocols. Restraints should only be used when absolutely necessary and with proper authorization to ensure the safety and well-being of the patient. Unauthorized use of restraints can lead to physical and psychological harm, and it is essential to follow established guidelines and obtain the necessary orders before applying restraints.

Choice B rationale

Administering the medication to a client behind a closed curtain is not a violation. This action ensures the client’s privacy and dignity during the administration of medication. Maintaining privacy is a standard practice in healthcare settings to respect the patient’s confidentiality and comfort.

Choice C rationale

Informing a client that the medication being administered is a vitamin is a violation of ethical and legal standards. It is essential to provide accurate information to the patient about the medication being administered. Misleading the patient can undermine trust and lead to potential harm if the patient has allergies or contraindications to the medication.

Choice D rationale

Enlisting security personnel to assist with restraining the client is not a violation if done appropriately. In situations where the client poses a danger to themselves or others, it may be necessary to involve security personnel to ensure safety. However, this should be done following proper protocols and with the necessary orders in place.

A. Using the syringe to remove the specimen from the catheter. B. Transporting the urine specimen to the laboratory. C. Recording the output on the flowsheet in the client’s room. D. Clamping the urinary catheter prior to the collection.

Correct Answer is A

Explanation

Choice A rationale

Using the syringe to remove the specimen from the catheter requires the nurse to wear gloves to maintain sterility and prevent contamination. Gloves protect both the nurse and the patient from potential pathogens present in the urine.

Choice B rationale

Transporting the urine specimen to the laboratory does not require gloves as the specimen is already secured in a biohazard bag, minimizing the risk of contamination.

Choice C rationale

Recording the output on the flowsheet in the client’s room does not involve direct contact with the urine specimen, so gloves are not necessary.

Choice D rationale

Clamping the urinary catheter prior to the collection does not require gloves as it is a preliminary step that does not involve direct contact with the urine.

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The nurse is assessing a client who is having pain in the right upper abdominal area. To assess the quality of the client’s abdominal pain, which approach should the nurse use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a violation?

Correct Answer is A

Explanation

The nurse uses a sterile syringe to obtain a urine specimen from a client’s indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear gloves?

Correct Answer is A

Explanation

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