A nurse in a pediatric unit is planning care for a group of clients. Which of the following clients should the nurse plan to use the Crying, Requires oxygen, Increased vital signs, Expression, Sleeplessness (CRIES) pain scale?

A 10-year-old client who had an appendectomy

A 3-year-old toddler who has a broken elbow

A 4-year-old preschooler who had a tonsillectomy

A 4-day-old infant who had a repair of a birth defect

Answer and Explanation

The Correct Answer is D

Choice A reason: The CRIES pain scale is not suitable for a 10-year-old as this scale is designed for neonates, typically those who are 0 to 6 months old.

Choice B reason: A 3-year-old toddler would be better assessed with a pain scale that allows for their level of understanding and communication, such as the Faces Pain Scale-Revised.

Choice C reason: A 4-year-old preschooler can typically communicate their pain verbally or by using a faces pain scale, making the CRIES scale less appropriate.

Choice D reason: The CRIES pain scale is specifically designed for neonates and is appropriate for assessing pain in a 4-day-old infant who cannot verbally communicate their pain.

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Correct Answer is D

Explanation

Choice A reason: The first and immediate action after a needlestick injury is to wash the puncture site with soap and water. This helps to remove any pathogens that may have been introduced into the puncture site.

Choice B reason: Squeezing the puncture site is not recommended because it can cause further injury to the tissue and does not effectively reduce the risk of bloodborne pathogen transmission.

Choice C reason: Flushing the puncture site with water is a good practice, but it should be done immediately, not just for 5 minutes. The initial washing is more critical.

Choice D reason: Postexposure prophylaxis (PEP) should be started as soon as possible, ideally within hours and no later than 72 hours after potential exposure to HIV. Waiting until the following day could decrease the effectiveness of PEP.

A. "I will avoid drinking large amounts of fluids immediately before bedtime." B. "I will limit having a glass of wine to just before bedtime." C. "I will walk briskly for 30 minutes before bedtime." D. "I will do my muscle relaxation techniques in the afternoon." E. Instruct the client about taking antifungal medications.

Correct Answer is A

Explanation

Choice A reason: Avoiding large amounts of fluids before bedtime can help prevent disruptions in sleep due to the need to urinate during the night.

Choice B reason: Consuming alcohol, even in the form of a glass of wine, just before bedtime can interfere with the sleep cycle and lead to disrupted sleep.

Choice C reason: Engaging in brisk exercise before bedtime can be stimulating and may make it more difficult to fall asleep.

Choice D reason: Performing muscle relaxation techniques in the afternoon can help reduce overall tension but doing them closer to bedtime would be more beneficial for promoting sleep.

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A nurse in a pediatric unit is planning care for a group of clients. Which of the following clients should the nurse plan to use the Crying, Requires oxygen, Increased vital signs, Expression, Sleeplessness (CRIES) pain scale?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse has accidentally punctured his finger with a needle he used to give an IM injection to a client. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is reinforcing teaching about promoting rest and sleep with a client who reports insomnia. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

Correct Answer is A

Explanation

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For documenting vital signs, the following documentation made by the nurse indicates an understanding of the teaching:

A nurse has accidentally punctured his finger with a needle he used to give an IM injection to a client. Which of the following actions should the nurse take?

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