The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?

Review the client's medical history and admission assessment.

Compare the client's current vital signs to the admission baseline.

Note how frequently doses of analgesics have been administered.

Ask the client to describe the intensity of the pain being experienced.

Answer and Explanation

The Correct Answer is D

Choice A reason: While the client's medical history and admission assessment provide valuable information, they do not directly measure the current pain experience.

Choice B reason: Vital signs can indicate pain but are not a definitive measure of pain severity as they can be influenced by other factors.

Choice C reason: The frequency of analgesic administration may suggest the level of pain control but does not measure the current pain intensity experienced by the client.

Choice D reason: Asking the client to describe the intensity of the pain is the most direct and effective way to assess pain severity. Pain is subjective, and the client's self-report is considered the gold standard for pain assessment.

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Correct Answer is C

Explanation

Choice A reason: Completing an admission assessment is typically the responsibility of a registered nurse (RN) due to the comprehensive nature of the assessment.

Choice B reason: Accessing a central venous line is usually within the scope of practice of an RN, not a PN, due to the complexity and potential complications associated with central lines.

Choice C reason: Reinforcing discharge teaching is an appropriate task for a PN, as it involves reviewing and ensuring the client understands the instructions already provided by the RN or healthcare provider.

Choice D reason: Initiating blood product infusions is generally the responsibility of an RN because of the critical nature of the task and the potential for adverse reactions.

A. Have the client sign a new surgical permit. B. Inform the surgeon about the client's concern. C. Add the additional information to the permit. D. Notify the surgical staff of the client's confusion.

Correct Answer is B

Explanation

Choice A reason: Having the client sign a new surgical permit is not necessary unless the surgeon agrees to the addition of the procedure after being informed.

Choice B reason: The nurse should inform the surgeon about the client's request to include the removal of the second lipoma. The surgeon will decide if it is feasible and safe to add the procedure to the current surgical plan.

Choice C reason: The nurse cannot unilaterally add procedures to a surgical permit; this must be done by the surgeon after evaluating the client's condition and the risks involved.

Choice D reason: Notifying the surgical staff of the client's confusion does not address the client's request and may not lead to a resolution of the issue.

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The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?

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Naxlex Comprehensive Predictor Exams

The nurse is planning assignments for the staff on a medical-surgical unit. Which task should the nurse assign to the practical nurse (PN)?

Correct Answer is C

Explanation

The nurse is reviewing the signed operative consent with a client who is admitted for the removal of a lipoma on the left leg. The client reports the permit should include another lipoma on the right leg. Which action should the nurse implement?

Correct Answer is B

Explanation

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