A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client’s pain level?

Pulse and blood pressure findings

Scheduled treatments and client illness

A self-report pain rating scale

Behavioral indicators and aﬀect

Answer and Explanation

The Correct Answer is C

Choice A Reason: This is incorrect. Pulse and blood pressure findings are not reliable indicators of pain, as they can be inﬂuenced by many other factors, such as anxiety, medication, or underlying conditions. They are also not sensitive enough to detect changes in pain intensity or relief.

Choice B Reason: This is incorrect. Scheduled treatments and client illness are not relevant parameters for assessing pain, as they do not reﬂect the current pain experience of the client. They may provide some clues about the possible causes or sources of pain, but they do not measure the pain itself.

Choice C Reason: This is correct. A self-report pain rating scale is the most valid and reliable parameter for assessing pain, as it reﬂects the subjective perception of the client. The nurse should use a simple and appropriate scale, such as a numeric or visual analog scale, and ask the client to point to the number or picture that best represents their pain level.

Choice D Reason: This is incorrect. Behavioral indicators and aﬀect are useful parameters for assessing pain, especially when the client has difficulty communicating verbally, but they are not the first choice. They are more subjective and variable than self-report, and they may be inﬂuenced by cultural or personal factors. They should be used in conjunction with self-report, not instead of it.

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Correct Answer is C

Explanation

Choice A Reason: This is incorrect because shortening of P-wave duration is not a sign of hyperkalemia or its reversal.

P-wave duration reﬂects the time it takes for the atria to depolarize and contract.

Choice B Reason: This is incorrect because restoration of QRS complex amplitude is not a sign of hyperkalemia or its reversal. QRS complex amplitude reﬂects the voltage or strength of the ventricular depolarization and contraction.

Choice C Reason: This is correct because the reduction of T-wave amplitude is a sign of hyperkalemia reversal. T-wave amplitude reﬂects the repolarization or recovery of the ventricles after contraction. Polystyrene sulfonate is a medication that lowers the serum potassium level by binding to it in the gastrointestinal tract and excreting it in the stool. High serum potassium level, or hyperkalemia, can cause cardiac arrhythmias and ECG changes, such as peaked T waves, prolonged PR interval, ﬂatened P waves, widened QRS complex, and ventricular fibrillation. By lowering the serum potassium level, polystyrene sulfonate can reverse these ECG changes and normalize the cardiac rhythm.

Choice D Reason: This is incorrect because the widening of the QRS complex is a sign of hyperkalemia, not its reversal. Widening of the QRS complex reﬂects the delay or impairment of ventricular depolarization and contraction.

A. Vesicles on the skin B. Respiratory failure C. Sloughing of skin D. Flu-like symptoms

Correct Answer is B

Explanation

Choice a) is incorrect because vesicles on the skin are a sign of cutaneous anthrax, not inhalation anthrax. Cutaneous anthrax is caused by direct contact with anthrax spores through a break in the skin. It causes a painless, black, necrotic lesion on the aﬀected area.

Choice b) is correct because respiratory failure is a sign of inhalation anthrax, which is the most deadly form of anthrax. Inhalation anthrax is caused by breathing in anthrax spores that enter the lungs and spread to the bloodstream. It causes severe breathing problems, chest pain, shock, and death.

Choice c) is incorrect because sloughing of skin is a sign of necrotizing fasciitis, not inhalation anthrax. Necrotizing fasciitis is a rare bacterial infection that destroys the soft tissue under the skin. It causes severe pain, swelling, redness, blisters, and gangrene.

Choice d) is incorrect because ﬂu-like symptoms are not specific to inhalation anthrax. Flu-like symptoms can be caused by many other conditions, such as inﬂuenza, common cold, or COVID-19. Flu-like symptoms include fever, cough, sore throat, headache, and muscle aches.

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A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client’s pain level?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate. If this medication is eﬀective, the nurse should expect which of the following changes on the client’s ECG?

Correct Answer is C

Explanation

A nurse is caring for a client who suspects recent exposure to inhalation anthrax. Which of the following findings indicate possible exposure?

Correct Answer is B

Explanation

A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?

A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client’s pain level?

A nurse is assisting with obtaining an electrocardiogram (ECG) for a client who has atrial fibrillation. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification?

A nurse is caring for a client who has bleeding esophageal varices and is being treated with a Sengstaken-Blakemore tube. Which of the following actions should the nurse perform?

A nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. Which of the following medications taken by the client interacts with contrast material and places the client at risk for acute kidney injury?

The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate?