A nurse is providing nonpharmacological interventions for a client who is experiencing pain. Which of the following actions should the nurse take?

Encourage the client to abstain from distracting activities.

Ensure that the client's room is kept at a cool temperature.

Play music in the client's room.

Keep the client's room well lit.

Answer and Explanation

The Correct Answer is C

Choice A Reason:

Encouraging the client to abstain from distracting activities is incorrect. Engaging in distracting activities can actually be beneficial in pain management. It can redirect the client's focus away from the pain, potentially reducing its intensity.

Choice B Reason:

Ensuring that the client's room is kept at a cool temperature is incorrect.

While temperature can influence comfort, maintaining a cool room might not directly address or alleviate the client's pain.

Choice C Reason:

Playing music in the client's room is correct. Music therapy is a nonpharmacological intervention that can effectively help in managing pain. Calming or soothing music can distract the client from pain, reduce anxiety, and promote relaxation, potentially reducing the perception of pain.

Choice D Reason:

Keep the client's room well-lit is incorrect. The lighting in the room might not significantly impact pain levels. Some individuals might prefer dim lighting for relaxation, but it might not directly influence pain perception.

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Correct Answer is B

Explanation

Choice A Reason:

Applying intermittent suction for up to 30 seconds is incorrect. While suctioning is necessary for tracheostomy care, the duration and frequency of suctioning should be based on the client's need and should typically last no more than 10-15 seconds to prevent hypoxemia and tissue damage.

Choice B Reason:

Preoxygenate the client prior to suctioning is correct. Preoxygenation helps ensure that the client has adequate oxygen levels before the suctioning procedure, reducing the risk of hypoxemia or decreased oxygen levels during and after suctioning

Choice C Reason:

Instruct the client to swallow during catheter insertion is incorrect. Instructing the client to swallow during catheter insertion is not a standard procedure for tracheostomy care. Swallowing doesn't have a direct association with the suctioning process.

Choice D Reason:

Apply suction while inserting the catheter is incorrect. Applying suction during catheter insertion can cause tissue damage and should be avoided. Suction should only be applied when withdrawing the catheter to remove secretions from the tracheostomy tube.

A. Turn the client every 4 hr. B. Cleanse the perineal area with povidone-iodine solution. C. Apply cornstarch powder to the perineal area. D. Place a moisture barrier ointment over the perineal area.

Correct Answer is D

Explanation

Choice A Reason:

Turn the client every 4 hr. is incorrect. While repositioning is crucial for preventing pressure ulcers in immobile patients, turning the client every 4 hours might not directly address the issue of fecal incontinence or skin protection in the perineal area.

Choice B Reason:

Cleanse the perineal area with povidone-iodine solution is incorrect. Povidone-iodine solution might be too harsh for routine perineal care and can potentially irritate the skin. A gentler cleansing solution is typically recommended to avoid further skin irritation.

Choice C Reason:

Apply cornstarch powder to the perineal area is incorrect. Cornstarch powder might exacerbate moisture-related skin issues in the perineal area by creating a damp environment, potentially leading to skin maceration and worsening skin problems. It's not typically recommended for use in managing fecal incontinence.

Choice D Reason:

Place a moisture barrier ointment over the perineal area is correct. Using a moisture barrier ointment can help protect the skin from irritation and breakdown caused by prolonged exposure to fecal matter, reducing the risk of skin breakdown and discomfort.

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A nurse is providing nonpharmacological interventions for a client who is experiencing pain. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for an older adult client who has fecal incontinence. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is collecting a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

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