A nurse is attending to a patient who is experiencing discomfort.
Which of the following patient statements should the nurse document in the initial pain assessment to describe the quality of the patient’s pain?

“I feel a dull ache in my stomach.”.

“I notice that the pain intensifies after I eat.”.

“The pain is causing me to feel nauseous.”.

“I’m experiencing mild pain.”.

Answer and Explanation

The Correct Answer is A

The quality of pain is a subjective description of what the pain feels like to the patient. The statement “I feel a dull ache in my stomach” provides a description of the quality of the patient’s pain.

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Correct Answer is B

Explanation

Choice A rationale

Inserting the catheter at a 45-degree angle is not recommended for an older adult client with fragile skin. A lower angle of insertion is usually more appropriate.

Choice B rationale

Positioning the client’s arm in a dependent position can help engorge the veins, making it easier to insert the IV catheter.

Choice C rationale

Removing excess hair from the insertion site is not the first action the nurse should take. While it’s important to have a clean and clear insertion site, positioning the client’s arm correctly is a more immediate concern.

Choice D rationale

Initiating IV therapy in the veins of the hand is not the first action the nurse should take. While the veins of the hand can be used for IV insertion, positioning the client’s arm correctly is a more immediate concern.

A. 36.5°C B. 37.5°C C. 38.5°C D. 39.5°C

Correct Answer is C

Explanation

Choice A rationale

A temperature of 36.5°C is considered normal.

Choice B rationale

A temperature of 37.5°C is slightly elevated but still within the normal range.

Choice C rationale

A temperature of 38.5°C is considered a fever. Given the client’s symptoms of a productive cough with thick yellow sputum and abnormal breath sounds, this could indicate an infection such as pneumonia, which would likely cause a fever.

Choice D rationale

A temperature of 39.5°C is a high fever and could indicate a severe infection. However, the client’s symptoms are more consistent with a moderate fever.

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A nurse is attending to a patient who is experiencing discomfort. Which of the following patient statements should the nurse document in the initial pain assessment to describe the quality of the patient’s pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to insert a peripheral IV catheter for an older adult client. Which action should the nurse plan to take?

Correct Answer is B

Explanation

The client was admitted with a productive cough with thick yellow sputum.Breath sounds with crackles were heard in the left upper lobe and decreased breath sounds at bases bilaterally. What is the client’s temperature?

Correct Answer is C

Explanation

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A nurse is attending to a patient who is experiencing discomfort.
Which of the following patient statements should the nurse document in the initial pain assessment to describe the quality of the patient’s pain?