Which of the following is most appropriate when the nurse assesses the intensity of the client's pain?

Use open-ended questions to find out about the sensation.

Offer the client a pain scale to quantify the current level of pain

Question the client about the location of the pain.

Ask about what precipitates the pain.

Answer and Explanation

The Correct Answer is B

A. Use open-ended questions to find out about the sensation: While open-ended questions can help the nurse gather information about the nature and quality of the pain, they may not provide a precise measure of pain intensity. Open-ended questions are valuable for understanding the client's subjective experience of pain, but they may not be as effective as using a pain scale for quantifying pain intensity.

B. Offer the client a pain scale to quantify the current level of pain: This is the most appropriate action for assessing pain intensity. Pain scales, such as the Numeric Rating Scale (NRS) or Visual Analog Scale (VAS), allow clients to indicate their pain intensity on a scale from 0 to 10 or by marking a point along a continuum. Pain scales provide a standardized method for quantifying pain intensity, which helps healthcare providers monitor changes in pain over time and assess the effectiveness of pain management interventions.

C. Question the client about the location of the pain: While identifying the location of pain is important for understanding its source and potential underlying causes, it does not directly assess pain intensity. Location is one aspect of pain assessment but does not provide a complete picture of pain intensity on its own.

D. Ask about what precipitates the pain: Understanding what precipitates or exacerbates pain is important for comprehensive pain assessment, but it focuses more on pain triggers rather than pain intensity. While this information can be valuable for developing a holistic pain management plan, it does not directly assess the current level of pain intensity.

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Correct Answer is ["B","C","D"]

Explanation

A. Reading back the calcium level result to the lab technician: Reading back results to the lab technician is a good practice to ensure accurate communication. The nurse verifies that they have received the correct information and confirms the accuracy of the result.

B. Document the time the call was received & the lab technician's name and date of birth. This was not selected because while documenting the time of the call and the lab technician's information may be useful for record-keeping purposes, it is not directly related to the immediate management of the client's low calcium level. Therefore, it is not essential to the immediate actions required in response to the lab result.

C. Reporting the elevated calcium level to the client's physician: An abnormally low calcium level (hypocalcemia) of 6.3 mg/dL requires prompt notification to the client's physician for further evaluation and intervention.

D. Confirming the client's full name, date of birth, & medical record number with the lab technician: Verifying the client's identity and medical record number ensures that the lab results are correctly matched to the right patient, minimizing the risk of errors in patient care.

E. Documenting the low calcium level in the client's electronic medical record: Documenting the calcium level in the client's electronic medical record ensures that the result is recorded for future reference and continuity of care. Accurate documentation is essential for tracking the client's health status and treatment outcomes.

A. Na+ 150 mEq/L B. Cl-95 mEq/L C. K+3.7 mEq/L D. HCO3-26 mEq/L

Correct Answer is A

Explanation

A. The elevated serum sodium (Na+) level of 150 mEq/L validates the symptoms of vomiting and diarrhea in the client. Vomiting and diarrhea lead to fluid loss and dehydration, resulting in an increased serum sodium concentration due to the loss of water from the body. Hypernatremia (elevated serum sodium) is consistent with dehydration resulting from prolonged vomiting and diarrhea. An elevated sodium level is indicative of hypertonic dehydration, where water loss exceeds electrolyte loss, leading to increased serum sodium concentration

B. Cl-95 mEq/L: Chloride (Cl-) is an electrolyte often lost in cases of vomiting and diarrhea due to the loss of gastric secretions and chloride-rich fluids. A chloride level of 95 mEq/L is slightly lower than normal (normal range: 96-106 mEq/L), which suggests mild chloride depletion.

C. K+3.7 mEq/L: Potassium (K+) levels within the normal range (3.5-5.0 mEq/L) do not necessarily validate symptoms of vomiting and diarrhea. While potassium loss can occur in cases of prolonged vomiting and diarrhea, the potassium level provided falls within the normal range.

D. HCO3-26 mEq/L: Bicarbonate (HCO3-) levels within the normal range (22-29 mEq/L) do not necessarily validate symptoms of vomiting and diarrhea. Elevated bicarbonate levels may indicate metabolic alkalosis, which can occur as a compensatory mechanism in response to acid loss through vomiting or diarrhea, but this value alone does not confirm the symptoms.

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Which of the following is most appropriate when the nurse assesses the intensity of the client's pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A lab technician calls to tell the nurse that their client's calcium level is 6.3 mg/dL. How will the nurse proceed with this information? (SELECT ALL THAT APPLY)

Correct Answer is ["B","C","D"]

Explanation

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Correct Answer is A

Explanation

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