When caring for a client who is receiving a warm, moist compress to relieve lower back pain, which of the following findings should indicate to the nurse that the compress has been effective?
The client's skin on the lower back is intact without redness.
The client states that he is able to concentrate while reading.
The client's vital signs are within the expected reference range.
The client is laughing at a television show.
The Correct Answer is A
This indicates that the compress has been effective in relieving lower back pain and has not caused any skin irritation or damage.
Choice B is wrong because the ability to concentrate while reading is not directly related to the effectiveness of a warm, moist compress for relieving lower back pain.
Choice C is wrong because vital signs being within the expected reference range does not necessarily indicate that the compress has been effective in relieving lower back pain.
Choice D is wrong because laughing at a television show does not necessarily indicate that the compress has been effective in relieving lower back pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Change the tubing set every 72 hr:Continuous enteral feeding tubing sets should generally be changed every 24 hours to reduce the risk of bacterial contamination. Changing every 72 hours is too long and increases infection risk.
B. Aspirate residual volume every 4 hr:Aspiration of residual volume every 4 hours is standard practice when providing continuous enteral feedings. This ensures the client is tolerating the feedings and helps prevent aspiration or overfeeding. Large residual volumes may indicate poor gastric emptying.
C. Flush the tubing with 10 mL of water every 2 hr:The tubing should be flushed with 30 mL of water every 4-6 hours (depending on protocol), not just 10 mL, to maintain tube patency and prevent clogging.
D. Heat the formula to 40.5° C (105° F):Formula should not be heated to such a high temperature. It should be administered at room temperature to avoid discomfort and potential damage to the gastrointestinal tract.
Correct Answer is C
Explanation
When caring for a client who has wrist restraints after an episode of violent behavior, the nurse should remove one restraint at a time.
This allows the nurse to assess the client’s behavior and response to having one arm free while still maintaining some level of control and safety.
Choice A is wrong because tying the restraints to the side rail can be dangerous as it can cause injury to the client if they move suddenly.
Choice B is wrong because removing the restraints every 3 hours is not a specific guideline and may vary depending on the facility’s policy and the client’s condition.
Choice D is wrong because securing restraints with a square knot can make it difficult to quickly release the restraints in an emergency.
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