The nurse is viewing 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.

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

Determine client’s objective measure of pain using a numerical pain scale.

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

Implement a 24-hour schedule of routine administration of prescribed analgesics.

Answer and Explanation

Correct Answer : B,C,E

Choice A rationale
Encouraging increased fluid intake and measuring urinary output every 8 hours is not directly related to managing chronic pain. This intervention is more relevant for clients with conditions affecting fluid balance or renal function.
Choice B rationale
Providing comfort measures such as topical warm application and tactile massage can help alleviate chronic pain by promoting relaxation and improving blood circulation. These non- pharmacological interventions can be effective in managing pain and enhancing the client’s comfort.
Choice C rationale
Determining the client’s objective measure of pain using a numerical pain scale is essential for assessing the severity of pain and evaluating the effectiveness of pain management interventions. Accurate pain assessment is crucial for developing an appropriate plan of care.
Choice D rationale
Assisting the client to ambulate as much as possible during waking hours may not be feasible for clients with severe chronic pain. While physical activity is important, it should be balanced with the client’s pain levels and overall condition.
Choice E rationale
Implementing a 24-hour schedule of routine administration of prescribed analgesics ensures consistent pain relief and prevents breakthrough pain. Regular administration of analgesics is a key component of effective pain management for clients with chronic pain.

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Correct Answer is D

Explanation

Choice A rationale
Entering the occurrence after the 1400 notes and identifying it as a “late entry” is an acceptable practice but may not provide sufficient clarity regarding the timing of the documentation.
Choice B rationale
Requesting removal initiated by the Health Information Manager is not necessary in this scenario. The focus should be on accurately documenting the missed occurrence rather than removing previously entered documentation.
Choice C rationale
Creating an electronic correction after 1400 notes are officially unlocked implies that there was an error in the original documentation. Since the issue here is not correcting an error but rather adding missed documentation, creating a correction may not be appropriate.
Choice D rationale
Making an electronic addendum following the 1400 documentation allows the nurse to add additional information to the chart without altering the original entry. This approach maintains the integrity of the original documentation while clearly indicating that the 0900 occurrence was added after the fact.

A. Administer a PRN sedative prescription. B. Leave the door to the client’s room open slightly. C. Apply wrist restraints to prevent wandering. D. Provide a back rub at bedtime.

Correct Answer is B

Explanation

Choice A rationale
Administering a PRN sedative prescription should not be the first intervention as it does not address the underlying cause of the client’s confusion and wandering.
Choice B rationale
Leaving the door to the client’s room open slightly can help reduce feelings of isolation and anxiety by allowing the client to see and hear staff members as they pass by.
Choice C rationale
Applying wrist restraints should be a last resort and not the first intervention for managing wandering behavior.
Choice D rationale
Providing a back rub at bedtime may help promote relaxation but does not directly address the issue of wandering.

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The nurse is viewing 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

After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?

Correct Answer is D

Explanation

A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?

Correct Answer is B

Explanation

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 attaches a pulse oximeter to a client’s finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

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

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The palliative care nurse receives a consult for a terminally ill client in the intensive care unit. The client is weak, mouth breathing, and refusing anything to eat or drink. Which intervention should the nurse include in the plan of care?

The nurse is viewing 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.