A nurse is applying a cold compress for pain and minor swelling for a client who has a sutured laceration on the forearm. Which of the following data-collection activities should the nurse use to determine whether the treatment is effective?

Having the client perform range-of-motion exercises of the arm

Inspecting the site for reduced swelling

Asking the client to rate the pain

Monitoring the client's pulse rate

Answer and Explanation

The Correct Answer is C

The correct answer is c. Asking the client to rate the pain. This is the most direct and reliable method to determine the effectiveness of a cold compress for pain relief.

Choice A Reason:

Having the client perform range-of-motion exercises of the arm: This statement is incorrect because it assesses mobility rather than pain or swelling. Range-of-motion exercises are typically used to evaluate joint flexibility and muscle strength, not the effectiveness of pain relief measures.

Choice B Reason:

Inspecting the site for reduced swelling: This statement is incorrect because, while it checks for swelling, it does not directly measure pain relief. Swelling reduction can be an indicator of decreased inflammation, but it does not provide a direct assessment of the client's pain levels.

Choice C Reason:

Asking the client to rate the pain: This is the correct choice because it directly measures the client's perception of pain. Pain is a subjective experience, and the most accurate way to assess it is by asking the client to describe or rate their pain. This method allows the nurse to gauge the effectiveness of the cold compress in providing pain relief.

Choice D Reason:

Monitoring the client's pulse rate: This statement is incorrect because pulse rate is not a direct indicator of pain or swelling reduction. While pain can sometimes cause an increase in pulse rate, it is not a reliable or specific measure of pain relief. Pulse rate can be influenced by various factors, including stress, anxiety, and physical activity.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: This documentation is correct as it includes the pulse rate and the client's position when the measurement was taken, which can affect the reading.

Choice B reason: The temperature is documented with the correct unit of measurement, but it does not specify the method of measurement (oral, axillary, tympanic, etc.), which is important for accurate interpretation.

Choice C reason: Respirations should be observed, not auscultated, and the documentation should include the client's position. The term 'even' is unnecessary and could be confusing.

Choice D reason: The blood pressure reading is correctly documented with both systolic and diastolic values. However, it should also include the client's position and the arm in which the measurement was taken for clarity.

A. Providing a newborn's first bath B. Giving personal care to an infant who is HIV-positive C. Suctioning secretions from a child's newly placed tracheostomy tube D. Withdrawing cord blood from a neonate E. Transporting a cerebrospinal fluid specimen to the laboratory

Correct Answer is C

Explanation

Choice A reason: While providing a newborn's first bath, there is minimal risk of exposure to infectious fluids that would necessitate eye protection. However, standard precautions should always be followed.

Choice B reason: When giving personal care to an infant who is HIV-positive, standard precautions should be followed, which includes wearing gloves. Eye protection is not typically required unless there is a risk of splashing bodily fluids.

Choice C reason: Suctioning secretions from a child's newly placed tracheostomy tube requires eye protection because there is a high risk of secretions being expelled forcefully, which could contact the mucous membranes of the eyes.

Choice D reason: Withdrawing cord blood from a neonate generally does not require eye protection unless there is a risk of blood splatter. Standard precautions, including the use of gloves, should be sufficient.

Choice E reason: Transporting a cerebrospinal fluid specimen to the laboratory does not require the nurse to wear eye protection. However, the nurse should ensure that the specimen is sealed properly to prevent any leaks.

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 nurse is applying a cold compress for pain and minor swelling for a client who has a sutured laceration on the forearm. Which of the following data-collection activities should the nurse use to determine whether the treatment is effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

A nurse is caring for a group of clients. For which of the following tasks should the nurse plan to wear protective eye equipment?

Correct Answer is C

Explanation

A patient has an elevated temperature. The nurse assesses the patient and finds the skin flushed and very warm. The patient is oriented to person, place, time, and situation, and expresses severe fatigue. The most appropriate nursing action at this time would be to:

A nurse is caring for a client who has pneumonia. The client's oxygen saturation is 88%. Which of the following actions should the nurse take first?

A nurse is caring for a client who has a wound infection that contains vancomycin-resistant Enterococcus (VRE). Which of the following types of precautions should the nurse plan to take while caring for this client?

When assessing a client's abdomen, particularly for "stomach pain," the nurse should:

A nurse is assisting with the admission of a client who has tuberculosis with a productive cough. Which type of isolation precautions should the nurse initiate for the client?

A nurse is changing the dressing on a client's wound. The nurse should recognize that which of the following findings is an indication of a wound infection?

A nurse is removing a wound dressing that is saturated with blood and purulent drainage. Which of the following methods should the nurse use when disposing of the soiled dressing?

A nurse inserts an indwelling urinary catheter for a client who is preoperative. Three days later, the client develops a urinary tract infection. The nurse should identify that the client has which of the following types of infections?