The nurse is reviewing the admission assessment of a client with chronic pain. What Intervention(s) should the nurse Include in the client's plan of care? Select all that apply.

Encourage Increased fluid intake and measure urinary output every 8 hours.

Assist the client to ambulate as much as possible during waking hours.

Determine client's subjective measure of pain using a numerical pain scale.

Provide comfort measures such as topical warm application and tactile massage.

Implement a 24 hour schedule of routine administration of prescribed analgesic.

Answer and Explanation

Correct Answer : B,C,D,E

A. Encourage increased fluid intake and measure urinary output every 8 hours:

While hydration and monitoring urinary output are important aspects of overall health care, they are not specifically related to managing chronic pain. Therefore, this intervention may not be directly relevant to addressing the client's pain.

B. Assist the client to ambulate as much as possible during waking hours:

Ambulation helps maintain mobility, prevent complications like muscle atrophy and deep vein thrombosis, and can improve overall well-being. For clients with chronic pain, assisting with ambulation can be beneficial in managing pain and improving quality of life. The goal is to balance activity with the client's pain tolerance and capabilities.

C. Determine client's subjective measure of pain using a numerical pain scale:

Using a numerical pain scale helps assess the intensity of pain and monitor changes over time. It provides valuable information for tailoring pain management strategies to the client's needs and allows for evaluating the effectiveness of interventions.

D. Provide comfort measures such as topical warm application and tactile massage:

Comfort measures such as warm applications and massage can help alleviate pain and promote relaxation. These interventions address the client's comfort and well-being, making them appropriate for inclusion in the plan of care for managing chronic pain.

E. Implement a 24-hour schedule of routine administration of prescribed analgesic:

Establishing a regular schedule of analgesic administration helps maintain consistent pain control and prevents breakthrough pain. This intervention is essential for managing chronic pain effectively and promoting the client's comfort and quality of life.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Inject in abdominal area at least 2 in (5.1 cm) from the umbilicus:

This instruction is accurate and appropriate for the administration of low molecular weight heparin subcutaneously. Injecting into the abdominal area at least 2 inches (5.1 cm) away from the umbilicus is a commonly recommended site for subcutaneous injections due to the availability of subcutaneous tissue and the reduced risk of injury to underlying structures.

B. Rotate injections between the abdomen and gluteal areas:

While rotation of injection sites is important to prevent tissue damage and lipodystrophy, for subcutaneous injections of low molecular weight heparin, the abdomen is typically the preferred site due to better absorption and reduced risk of complications. Therefore, rotating between the abdomen and gluteal areas may not be necessary or recommended for this specific medication.

C. Expel the air in the prefilled syringe prior to injection:

Expelling air from the prefilled syringe is a standard practice to ensure accurate dosing and prevent air embolism, but it is not specific to the administration of low molecular weight heparin. This instruction should be included in general injection technique education but is not specific to the administration of this medication.

D. Massage the injection site to increase absorption:

Massaging the injection site after administration of low molecular weight heparin is not recommended, as it can increase the risk of bleeding or hematoma formation at the injection site. Massaging the site is generally contraindicated for anticoagulant injections to avoid disrupting the clotting process.

A. Elevate the head of the bed to a 45 degree angle. B. Lift and lock the side rails in place. C. Apply the client's positive airway pressure device. D. Remove dentures or other oral appliance.

Correct Answer is C

Explanation

A. Elevate the head of the bed to a 45-degree angle:

Elevating the head of the bed can help improve airway patency and reduce the risk of airway obstruction in clients with OSA. While this intervention is important, applying the positive airway pressure device (CPAP or BiPAP) takes precedence due to its direct impact on maintaining airway patency and preventing respiratory compromise.

B. Lift and lock the side rails in place:

Ensuring the safety of the client by lifting and locking the side rails is important, but it does not directly address the client's OSA or the potential respiratory depression associated with opioid analgesic administration.

C. Apply the client's positive airway pressure device:

This is the most important intervention in this scenario. Clients with severe obstructive sleep apnea rely on positive airway pressure devices, such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP), to maintain airway patency and prevent episodes of apnea during sleep. Applying the device before leaving the client alone ensures continuous support for effective breathing.

D. Remove dentures or other oral appliance:

While removing dentures or other oral appliances may be necessary for client comfort and safety, it is not directly related to managing OSA or preventing respiratory compromise associated with opioid analgesic administration.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is reviewing the admission assessment of a client with chronic pain. What Intervention(s) should the nurse Include in the client's plan of care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching the client to self administer a dose of low molecular weight heparin SUBQ. Which instruction should the nurse Include?

Correct Answer is A

Explanation

A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which Intervention is most important for the nurse to implement before leaving the client alone?

Correct Answer is C

Explanation

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?

The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL. vial. Which action should the nurse perform with the remainder of the medication?

The nurse is teaching a client about a newly prescribed medication. To confirm that the client is learning the critical information, which strategy is most important for the nurse to include during the instruction?

The nurse is demonstrating three point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior Indicates that the client understands proper crutch walking?

The healthcare provider prescribes streptomycin 200 mg IM every 12 hours. The vial is labeled, "Streptomycin 1 gram/2.5 mL." How many milliliters should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

The nurse is teaching a client about use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client's parents arrive and are asking questions about the client's laboratory results. Which response is best for the nurse to provide?