A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain.
Which of the following statements by the client indicates an understanding of this technique?

“I’ll learn to notice the sensation of muscle tension.”

“I’ll listen to my favorite music to take my mind off the pain.”

“I’ll use focused breathing to control my pain.”.

“I’ll think about my grandfather’s farm to reduce pain.”.

Answer and Explanation

The Correct Answer is D

The correct answer is choice D. “I’ll think about my grandfather’s farm to reduce pain.” This statement indicates an understanding of guided imagery, which is a relaxation technique that aims to help lower the levels of stress hormones and pain perception by imagining a scene that involves each of the senses and positive emotions.

Guided imagery can help to distract from pain signals and reduce anxiety, which can also contribute to pain.

Choice A is wrong because it does not involve creating a specific imagined reality, but rather noticing the sensation of muscle tension, which may increase awareness of pain.

Choice B is wrong because it does not involve using all of the senses and emotions, but rather listening to music, which may be relaxing but not as effective as guided imagery for pain relief.

Choice C is wrong because it does not involve imagining a scene, but rather using focused breathing to control pain, which is another relaxation technique but not guided imagery.

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Correct Answer is D

Explanation

The correct answer is D. Using two gloved fingers to open the client’s mouth for cleaning.

Choice A rationale:

Lowering the side rail on the side of the bed where the AP will stand is necessary for safe access to the client. However, the AP should ensure the opposite side rail is up to prevent the client from falling.

Choice B rationale:

Using an oral care sponge swab moistened with cool water is an appropriate method for cleaning the mouth of an unconscious client. It helps maintain oral hygiene and comfort.

Choice C rationale:

Wearing clean gloves is essential for infection control and is a standard practice when performing mouth care to protect both the client and the caregiver.

Choice D rationale:

Using two gloved fingers to open the client’s mouth is not recommended as it can cause injury to the caregiver if the client bites down reflexively. Instead, a padded tongue blade should be used to gently open the mouth.

A. Reposition the sensor probe. B. Apply a cooling blanket to the client. C. Place the client in a side-lying position. D. Ambulate the client.

Correct Answer is A

Explanation

The client’s oxygen saturation is 88% on 2 L/min of oxygen via nasal cannula, which is below the normal range of 95% to 100%.

This could indicate that the client is not receiving enough oxygen or that the pulse oximeter is not working properly.

The nurse should first check the sensor probe for any problems, such as poor attachment, nail polish, cold extremities, or motion artifact.

Repositioning the sensor probe may improve the accuracy of the reading and help the nurse determine the next course of action.

Choice B. Apply a cooling blanket to the client is wrong because a cooling blanket is used to lower the body temperature of a client with fever or hyperthermia.

It has no effect on the oxygen saturation level.

Choice C. Place the client in a side-lying position is wrong because a side-lying position may not improve the oxygenation of the client.

A more appropriate position would be a high Fowler’s position, which allows for maximum lung expansion and gas exchange.

Choice D. Ambulate the client is wrong because ambulating the client may worsen the oxygen saturation level if the client has a respiratory condition that causes hypoxemia.

The nurse should assess the client’s respiratory status and oxygen therapy before ambulating the client.

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A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client indicates an understanding of this technique?

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Naxlex Comprehensive Predictor Exams

A nurse observes assistive personnel (AP) perform mouth care for a client who is unconscious. Which of the following actions by the AP requires intervention by the nurse?

Correct Answer is D

Explanation

A nurse is monitoring a client’s oxygen saturation using a pulse oximeter. The client’s oxygen saturation is 88% on 2 L/min of oxygen via nasal cannula. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is collecting data about a client’s oral care. The client wears dentures and reports having mouth sores. The nurse should identify which of the following oral care practices by the client as a possible cause of the mouth sores?

A nurse is assisting in the transfer of a client who has left-sided weakness from a bed to a chair. Which of the following actions should the nurse take?

A nurse is caring for a client who was recently admitted to hospice care and tells the nurse, “I am going to die and my family is hoping for a cure. I am mad that they behave like everything will be fine.” Which of the following responses should the nurse make?

A nurse is reinforcing information with a client who wishes to complete their advance directives. Which of the following statements should the nurse make?

A nurse is caring for a client who has experienced a cerebrovascular accident with resulting dysphagia. Which of the following therapists assists clients to learn to eat with less risk of aspiration?

A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client’s room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?

A nurse is inserting an indwelling urinary catheter for a female client. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.).

A nurse is reinforcing teaching with a client who needs to increase vitamin C intake to promote wound healing. Which of the following foods should the nurse recommend as the best source of vitamin C?

A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain.
Which of the following statements by the client indicates an understanding of this technique?