A nurse is caring for a client who is receiving a warm, moist compress to relieve lower back pain. Which of the following findings should indicate to the nurse that the compress has been effective?
The client is laughing at a television show.
The client's skin on the lower back is intact without redness.
The client states that he is able to concentrate while reading.
The client's vital signs are within the expected reference range.
The Correct Answer is B
Choice A rationale:
Laughing at a television show is not a direct indicator of the effectiveness of the warm, moist compress in relieving lower back pain.
Choice B rationale:
Intact skin on the lower back without redness indicates that the compress has been effective in preventing skin damage or irritation.
Choice C rationale:
The ability to concentrate while reading may not be a specific indicator of the effectiveness of the warm compress in relieving lower back pain.
Choice D rationale:
Vital signs within the expected reference range are important but do not directly reflect the effectiveness of the warm compress in relieving pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Tuberculosis is transmitted via airborne droplets, so airborne precautions are necessary. The nurse should wear an N95 respirator mask when caring for the client, and the client should be placed in a negative pressure room. Airborne precautions include wearing a respirator mask, placing the client in a negative pressure room, and limiting the movement of the client outside the room.
Choice B rationale:
Droplet precautions are used for infections that are spread by large respiratory droplets, such as influenza or pertussis.
Choice C rationale:
Contact precautions are used for infections that are spread by direct or indirect contact with the client or their environment, such as scabies or Clostridium difficile.
Choice D rationale:
Protective precautions are used for clients who are immunocompromised and at risk of infection from others, such as those who have had a stem cell transplant or chemotherapy.
Correct Answer is A
Explanation
Choice A rationale:
This response is correct. ALT (alanine aminotransferase) is an enzyme found in the liver. An elevated ALT level may indicate liver damage or disease.
Choice B rationale:
ALT is not specific to kidney function.
Choice C rationale:
ALT does not provide information about heart function.
Choice D rationale:
ALT is not associated with the risk of developing blood clots.
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