. A nurse is caring for a postoperative client. The nurse should base the client's pain management interventions primarily on which methods of determining the intensity of the client's pain?

The patient's chart

Visual observation for nonverbal signs of pain

The client's self-report of pain severity

The nature and invasiveness of the surgical procedure

Answer and Explanation

The Correct Answer is C

A. The patient's chart may provide historical information but does not reflect the current pain intensity the client is experiencing.

B. Visual observation for nonverbal signs of pain can be useful, especially for nonverbal patients, but self-reporting is the most accurate measure of pain intensity.

C. The client's self-report of pain severity is the gold standard for assessing pain intensity, as it reflects the individual’s personal experience of pain.

D. While the nature and invasiveness of the surgical procedure can provide context for expected pain levels, they do not replace the importance of the client's self-report in managing pain effectively.

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Correct Answer is D

Explanation

A. The tympanic temperature of 37.1° C (98.8° F) is within normal limits and does not require re-measurement.

B. The respiratory rate of 14/min is also within the normal range (12-20 breaths per minute).

C. The blood pressure of 98/77 mm Hg is not alarmingly low and does not require immediate re-measurement.

D. A pulse rate of 42/min indicates bradycardia (normal resting heart rate is typically between 60-100 bpm), so it is important to re-measure to confirm this finding and assess the client's cardiovascular status.

A. The diaphragm of the stethoscope is used for low-pitched sounds. B. The binaural should fit snugly in the ears. C. Short tubing provides the listener with the most accurate sounds. D. The bell of the stethoscope is used for high-pitched sounds, such as lung sounds. E. The stethoscope works by blocking out environmental sounds.

Correct Answer is ["B","C","E"]

Explanation

A. The diaphragm of the stethoscope is used for high-pitched sounds, such as lung and normal heart sounds, not low-pitched sounds.

B. The binaural (earpieces) should fit snugly in the ears to ensure proper sound transmission and clarity.

C. Short tubing provides more accurate sounds by minimizing sound distortion, making it ideal for clinical use.

D. The bell of the stethoscope is used for low-pitched sounds, such as heart murmurs, not high-pitched sounds.

E. The stethoscope works by blocking out environmental sounds to help the user focus on internal body sounds.

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. A nurse is caring for a postoperative client. The nurse should base the client's pain management interventions primarily on which methods of determining the intensity of the client's pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 42/min, respiratory rate 14/min, and BP 98/77 mm Hg. Which vital sign should the nurse re-measure?

Correct Answer is D

Explanation

The nurse is teaching a group of unlicensed assistive personnel about the stethoscope. Which statements about the stethoscope are appropriate for the nurse to include in the teaching session? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

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