A nurse is assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain?

A client who has peritonitis reports generalized abdominal pain.

A client who has angina reports substernal chest pain.

A client who has pancreatitis reports pain in the left shoulder.

A client who is postoperative reports incisional pain.

Answer and Explanation

The Correct Answer is C

Referred pain is pain that is felt in a location different from its source due to shared nerve pathways or central nervous system processing. A client who has pancreatitis may experience pain in the left shoulder due to irritation of the diaphragm by pancreatic enzymes or inflammation. This pain is referred from the abdominal cavity to the shoulder through the phrenic nerve.

A client who has peritonitis reports generalized abdominal pain that corresponds to the site of inflammation and infection in the peritoneum. A client who has angina reports substernal chest pain that reflects the ischemia and hypoxia of the myocardium. A client who is postoperative reports incisional pain that is caused by tissue damage and inflammation at the surgical site.

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Correct Answer is C

Explanation

A frozen fruit juice bar for dessert is a low-sodium option that can satisfy the client's sweet tooth. According to the National Health and Nutrition Examination Survey, Americans consume about 3700 mg of sodium daily, which is much higher than the recommended 2300 mg for the general population and 1500 mg for those with heart failure. Excessive sodium intake can lead to fluid retention, hypertension, and worsening of heart failure symptoms. Therefore, the client should avoid high-sodium foods such as vegetable juice, garlic and onion salts, and mayonnaise.

A. Administer oxygen to the client. B. Collect a urine sample. C. Check the client's vital signs. D. Stop the infusion.

Correct Answer is D

Explanation

The client is experiencing signs of an acute hemolytic transfusion reaction, which is a life-threatening emergency. The nurse should stop the infusion immediately and disconnect the blood tubing from the IV catheter to prevent further exposure to the incompatible blood.

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A nurse is assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake to 2 g per day. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye. Which of the following actions should the nurse plan to take first?

A nurse is caring for a client following a total knee arthroplasty. The client reports a pain level of 6 on a pain scale of 0 to 10. Which of the following interventions should the nurse take?

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