To assess the quality of an adult client's pain, which approach should the nurse use?

Identify effective pain relief measures.

Provide a numeric pain scale.

Ask the client to describe the pain.

Observe body language and movement.

Answer and Explanation

The Correct Answer is C

C. Asking the client to describe their pain allows the nurse to gather subjective information directly from the client, which can provide valuable insight into the quality, intensity, location, and duration of the pain.

A. This option focuses on pain management rather than pain assessment. While identifying effective pain relief measures is important, it does not directly address the need to assess the quality of the client's pain.

B. While numeric pain scales can be useful for quantifying pain intensity, they do not capture the quality or characteristics of the pain.

D. Observing body language and movement can provide valuable information about the client's pain experience, such as grimacing, guarding, or difficulty moving. However, this approach primarily assesses pain behaviors rather than the quality of the pain itself.

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Free Nursing Study Resources

Correct Answer is ["A","B","D","E","G"]

Explanation

A. Hand hygiene is essential to prevent the transmission of microorganisms and maintain infection control standards.
B. Verifying the client's identity using two unique identifiers, such as name and date of birth, helps prevent errors and ensures that the intervention is performed on the correct individual.
D. Assessing the skin around the face helps identify any abnormalities, irritation, or contraindications to applying the face mask, such as open wounds or dermatitis.
E. Wearing gloves helps prevent the transmission of microorganisms and protects both the nurse and the client during the application of the face mask.
G. Assessing respiratory function helps determine the client's need for the face mask and ensures that it is applied appropriately based on the client's respiratory status and needs.
C. While it's important to address the client's toileting needs, determining whether the client needs to go to the bathroom is not directly related to the application of a face mask unless there are specific concerns about the client's comfort or ability to tolerate the mask.
F. Brushing the client's teeth is not typically performed before applying a face mask unless there are specific clinical indications or the client requests oral care. However, oral care may be performed as part of routine hygiene practices or if the client is intubated and oral hygiene is necessary.

A. Rhonchi in the right lung B. Symmetric chest expansion C. Oxygen saturation greater than 949% D. PaCO2 55 mm Hg on a blood gas E. Client ambulates without shortness of breath F. Diminished breath sounds in the right lung

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

A. Rhonchi are abnormal breath sounds that indicate the presence of mucus or fluid in the airways. Finding rhonchi in the right lung suggests the presence of respiratory congestion or obstruction, which may indicate ineffective treatment or ongoing respiratory issues.

B. Symmetric chest expansion indicates equal and adequate movement of both sides of the chest during inhalation. This finding suggests that there are no restrictions or abnormalities in the chest wall or lung tissue, which is indicative of effective treatment.

C. Oxygen saturation greater than 94% indicates adequate oxygenation of the blood, which is a positive indicator of effective treatment, particularly in clients with respiratory issues such as pneumonia or COPD.

D. A PaCO2 level of 55 mm Hg indicates hypercapnia, which is an elevated level of carbon dioxide in the blood. This finding suggests inadequate ventilation or respiratory failure, indicating ineffective treatment.

E. The ability to ambulate without experiencing shortness of breath suggests improved respiratory function and effective treatment, as it indicates adequate oxygenation and ventilation.

F. Diminished breath sounds suggest reduced airflow or lung volume in the affected area. This finding may indicate ongoing respiratory issues or incomplete resolution of the condition, suggesting ineffective treatment.

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To assess the quality of an adult client's pain, which approach should the nurse use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits What should the nurse do before applying the face mask? Select that apply.

Correct Answer is ["A","B","D","E","G"]

Explanation

Patient Data Exhibits Mark whether the assessment findings indicate that the treatment was effective or ineffective. Assessment Findings

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

The healthcare provider prescribes bismuth subsalicylate, metronidazole, tetracycline, and pantoprazole for a client with a Helicobacter pylori (H. pylori) infection. Prior to administering the H. pylori treatment regimen, the nurse should review the electronic medical record for which medication?

A client with emphysema reports difficulty breathing and exhibits audible wheezing. The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants Immediate intervention by the nurse?

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While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Patient Data Exhibits What actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.

The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?