A bedfast female client awakens during the night, reporting to the nurse that she is "uncomfortable." What action should the nurse implement first?

Engage the client in relaxation exercises.

Offer to sit with the client until she relaxes.

Administer a prescribed PRN analgesic.

Assist the client to a different position.

Answer and Explanation

The Correct Answer is D

A. Engaging the client in relaxation exercises may be helpful but should be considered after addressing potential physical causes of discomfort, such as positioning.
B. Offering to sit with the client is supportive, but the primary issue of physical discomfort should be addressed first.
C. Administering a PRN analgesic may be necessary if the discomfort persists, but repositioning the client is a less invasive intervention to try first.
D. Assisting the client to a different position is the first action the nurse should take. A change in position can often alleviate discomfort for bedfast clients and is a simple, non-invasive intervention.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

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

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Reducing the amount of pressure applied is the appropriate next step because excessive pressure can occlude the pulse, making it difficult to feel. Lightening the pressure may help the nurse detect the pulse.
B. Palpating the posterior tibial pulse (below the medial malleolus) is another option if the dorsalis pedis pulse is not palpable, but it should be attempted only after ensuring that proper technique was used to feel the dorsalis pedis pulse.
C. Using a Doppler stethoscope is a good option if the pulse remains non-palpable after proper technique has been used. However, it is not the immediate next step.
D. Documenting that the dorsalis pedis pulse is not palpable should be done after all appropriate steps, including adjusting the pressure and possibly using a Doppler, have been attempted.

A. Dizziness can occur during cleansing. B. Foreskin should not be retracted. C. An erection may occur while providing care. D. Pubic area should be kept shaved.

Correct Answer is C

Explanation

A. Dizziness is not typically associated with routine perineal care, so it is not a common concern for the caregiver to monitor during cleansing. Normal care does not usually affect blood pressure or circulation enough to cause dizziness.

B. The foreskin should be gently retracted in male clients who are uncircumcised to clean beneath it, as failing to do so can lead to buildup of secretions and increase the risk of infection. Proper retraction is important for hygiene and to prevent conditions like balanitis.

C. An erection may occur as a reflex response during perineal care, especially in males with intact neurologic function. Caregivers should be aware of this possibility and continue care calmly and professionally without assuming it is sexual in nature.

D. The pubic area does not need to be shaved for routine hygiene, and shaving can cause microabrasions that increase the risk of infection. Proper cleansing with soap and water is sufficient to maintain perineal hygiene.

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

A bedfast female client awakens during the night, reporting to the nurse that she is "uncomfortable." What action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To assess a client's dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes, but does not feel a pulsation. Which action should the nurse take next?

Correct Answer is A

Explanation

The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?

Correct Answer is C

Explanation

A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?

The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?

While electronically scanning the client's armband at the bedside prior to administering pain medication, the nurse observes the power flickers and the computer screen goes blank. The computer fails to reboot and the screen remains dark. Which action should the nurse do first?

The mother of a child born with Tetralogy of Fallot asks the nurse, "Why did this happen to my baby? What did I do wrong?" Which response by the nurse is most helpful?

The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

A client is requesting medicine for pain 30 minutes after receiving morphine sulfate 5 mg intravenously. Which intervention should the nurse implement next?

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

In-home hospice care is arranged for a client with stage 4 lung cancer. While the palliative care nurse is arranging for discharge, the client verbalizes concerns about pain. Which action should the nurse implement?