A nurse is planning care for a client who has acute pain as a result of a pressure injury to the sacrum. Which of the following nonpharmacological Interventions should the nurse include in the plan?

Loosen the client's bed linens.

Provide bright lights in the client's room.

Massage the client's sacrum.

Offer to play music in the client's room.

Answer and Explanation

The Correct Answer is D

A. Loosen the client's bed linens:

For support surfaces to be effective, there must be minimal layering in between the device and the person. A single sheet that can be kept dry and crease free is optimal. Loosening linens can help make the client more comfortable by reducing pressure and friction on the skin, but it does not directly address the client's acute pain from a pressure injury.

B. Provide bright lights in the client's room:

Bright lights may not be directly relevant to managing acute pain from a pressure injury. In fact, some clients may prefer a dimly lit environment when experiencing pain. Therefore, this option is not the most appropriate for pain management in this case.

C. Massage the client's sacrum:

Massaging the client's sacrum is not recommended when there is a pressure injury, as this could further damage the tissue and exacerbate the injury.

D. Offer to play music in the client's room:

Music therapy is a widely recognized nonpharmacological intervention for pain management. Listening to music can reduce the perception of pain by distracting the client, promoting relaxation, and triggering the release of endorphins. This approach is safe, inexpensive, and can be tailored to the client’s preferences.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. An assistive personnel prevents a client from leaving the facility:

This situation may raise ethical concerns related to patient autonomy and freedom of movement. However, it is not a clear example of negligence. Negligence is more directly related to the provision of care and the failure to meet the standard of care.

B. An assistive personnel discusses client care in the facility cafeteria with visitors present:

This situation involves a breach of confidentiality and may violate the Health Insurance Portability and Accountability Act (HIPAA). However, it is not an example of negligence. Negligence typically involves a failure to provide appropriate care rather than a breach of privacy.

C. A nurse administers a medication without first identifying the client:

This is an example of negligence. Negligence refers to the failure to provide the standard of care that a reasonably prudent person would have provided under similar circumstances. In this case, administering medication without first identifying the client is a breach of the standard of care, and it can lead to serious consequences, including harm to the patient.

D. A nurse begins a blood transfusion without obtaining consent from a client:

This is an example of a legal issue related to lack of informed consent. While it raises ethical and legal concerns, it may not necessarily be considered negligence, which is more related to a failure in providing care up to the standard. However, it is still a serious violation of ethical and legal principles.

A. Endotracheal suctioning B. Urinary catheter care C. Enteral feeding D. Wound Irrigation

Correct Answer is A

Explanation

A. Endotracheal suctioning:

This is the correct answer. If a client requires endotracheal suctioning, it is likely due to respiratory distress or compromised airway clearance. Ensuring a patent airway and maintaining adequate oxygenation is the top priority, making endotracheal suctioning the first procedure to be performed.

B. Urinary catheter care:

Urinary catheter care is important for preventing infections and maintaining urinary function, but it is generally not as urgent as addressing respiratory distress. If the client is experiencing respiratory issues, addressing these concerns should take precedence.

C. Enteral feeding:

While enteral feeding is essential for providing nutrition, it is not typically as urgent as addressing respiratory needs. If a client requires endotracheal suctioning for respiratory support, it should be prioritized over enteral feeding.

D. Wound irrigation:

Wound irrigation is important for wound care, but it is generally not as time-sensitive as addressing respiratory needs. If the client's airway is compromised, it takes precedence over wound irrigation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is planning care for a client who has acute pain as a result of a pressure injury to the sacrum. Which of the following nonpharmacological Interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collaborating with a risk management team about potential legal issues involving client care. The nurse should identify that which of the following situations is an example of negligence?

Correct Answer is C

Explanation

A nurse is prioritizing care for a client. Which of the following procedures should the nurse perform first?

Correct Answer is A

Explanation

A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?

A nurse is caring for a client who has left lower-lobe atelectasis. In which of the following positions should the nurse place the client for postural drainage?

A nurse is obtaining a health history from a client. Which of the following factors places the client at risk for cardiovascular disease?

A nurse is planning care for a client who is immobile. Which of the following actions should the nurse include in the plan of care?

A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?

A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse's priority?

A nurse is caring for a client who has a terminal illness. The client states, "I am not giving up. I want as much treatment as possible." Which of the following responses should the nurse make?