A priority goal of the nursing pain assessment is to:

Demonstrate a caring attitude to the patient and family.

Ensure complete documentation in the EHR.

Gather subjective and objective data in order to plan and implement appropriate pain management techniques.

Develop a therapeutic relationship with the patient.

Answer and Explanation

The Correct Answer is C

Choice A: Demonstrate a caring attitude to the patient and family
While demonstrating a caring attitude is an essential aspect of nursing, it is not the primary goal of pain assessment. A caring attitude helps build trust and rapport with patients and their families, which is crucial for effective communication and overall patient care. However, the main objective of pain assessment is to gather data that will inform pain management strategies.
Choice B: Ensure complete documentation in the EHR
Ensuring complete documentation in the Electronic Health Record (EHR) is important for maintaining accurate patient records and facilitating communication among healthcare providers. However, this is a secondary goal that supports the primary objective of pain assessment. The main focus of pain assessment is to collect data that will guide pain management interventions.
Choice C: Gather subjective and objective data in order to plan and implement appropriate pain management techniques
This is the correct answer. The primary goal of a nursing pain assessment is to gather both subjective data (patient’s self-reported pain levels, descriptions, and experiences) and objective data (observations, vital signs, and physical assessments). This comprehensive data collection allows nurses to develop and implement effective pain management plans tailored to the individual needs of the patient. Accurate pain assessment is crucial for identifying the type, intensity, and cause of pain, which in turn informs the selection of appropriate pain relief measures.
Choice D: Develop a therapeutic relationship with the patient
Developing a therapeutic relationship with the patient is an important aspect of nursing care, as it fosters trust and open communication. However, it is not the primary goal of pain assessment. The main objective of pain assessment is to gather data that will inform pain management strategies. A therapeutic relationship can enhance the effectiveness of pain assessment and management, but it is a means to an end rather than the end itself.

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Correct Answer is A

Explanation

Choice A: Show the caregiver how to check the patient’s temperature and blood pressure
Showing the caregiver how to check the patient’s temperature and blood pressure involves direct patient education and demonstration, which requires the clinical judgment and expertise of a licensed nurse. This task ensures that the caregiver understands the correct techniques and can accurately monitor the patient’s vital signs. Delegating this task to assistive personnel (AP) is not appropriate because it requires a higher level of skill and knowledge to teach and verify understanding.
Choice B: Give the patient a pamphlet that reinforces teaching done by the nurse
Giving the patient a pamphlet that reinforces teaching done by the nurse is a task that can be delegated to assistive personnel (AP). This action does not require clinical judgment or advanced skills. The pamphlet serves as a supplementary resource to the verbal and hands-on education provided by the nurse. It is a straightforward task that AP can perform, ensuring that the patient has access to written information that reinforces the nurse’s teaching.
Choice C: Evaluate whether the patient and caregiver understand the teaching
Evaluating whether the patient and caregiver understand the teaching is a critical component of the discharge process that requires the clinical judgment of a licensed nurse. This task involves assessing the patient’s and caregiver’s comprehension, identifying any gaps in understanding, and providing additional education as needed. It is not appropriate to delegate this responsibility to assistive personnel (AP) because it requires professional assessment skills.
Choice D: Plan topics for the discharge teaching session with the patient and caregiver
Planning topics for the discharge teaching session with the patient and caregiver involves developing a comprehensive and individualized teaching plan based on the patient’s specific needs and condition. This task requires the expertise and clinical judgment of a licensed nurse to ensure that all relevant topics are covered and that the teaching plan is tailored to the patient’s situation. Delegating this task to assistive personnel (AP) is not appropriate because it requires advanced planning and professional knowledge.

A. Monitor for signs and symptoms of infection. B. Provide all patients with bottled water. C. Provide education on infection prevention. D. Request an antibiotic order for a febrile patient. E. Create a clean, safe environment.

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

Explanation

Choice A: Monitor for signs and symptoms of infection

Monitoring for signs and symptoms of infection is a fundamental strategy in infection prevention. Early detection of infections allows for timely intervention, which can prevent the spread of pathogens and reduce the severity of the infection. Common signs and symptoms include fever, redness, swelling, pain, and discharge. Regular monitoring helps healthcare providers identify infections early and take appropriate actions, such as isolating the patient or starting treatment.

Choice B: Provide all patients with bottled water

Providing all patients with bottled water is not a standard infection prevention strategy. While ensuring access to clean drinking water is important, it is not specifically aimed at preventing infections. In healthcare settings, tap water is usually safe to drink if it meets regulatory standards. Bottled water may be provided in certain situations, such as during an outbreak of waterborne pathogens, but it is not a routine infection prevention measure.

Choice C: Provide education on infection prevention

Providing education on infection prevention is crucial for both healthcare providers and patients. Education helps individuals understand how infections spread and what measures they can take to prevent them. This includes proper hand hygiene, respiratory etiquette, and the importance of vaccinations. Educating patients and staff can significantly reduce the incidence of healthcare-associated infections by promoting adherence to infection control practices.

Choice D: Request an antibiotic order for a febrile patient

Requesting an antibiotic order for a febrile patient is not an infection prevention strategy but rather a treatment approach. Antibiotics are used to treat bacterial infections, not to prevent them. Overuse of antibiotics can lead to antibiotic resistance, making it crucial to use them judiciously and only when necessary. Infection prevention focuses on measures to prevent the occurrence of infections rather than treating them once they occur.

Choice E: Create a clean, safe environment

Creating a clean, safe environment is essential for infection prevention in healthcare settings. This involves regular cleaning and disinfection of surfaces, proper waste disposal, and maintaining hygiene standards. A clean environment reduces the risk of healthcare-associated infections by minimizing the presence of pathogens. Effective cleaning protocols and environmental controls are critical components of infection prevention strategies.

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A priority goal of the nursing pain assessment is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which actions included in the discharge teaching plan can the nurse delegate to assistive personnel (AP)?

Correct Answer is A

Explanation

Infection prevention strategies include:

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

Explanation

IV potassium chloride (KCl) 60 mEq is prescribed for a 49-year-old female patient with severe hypokalemia. Which action should the nurse take?

The nurse is assigned to care for a newly admitted patient. Place the steps for using the nursing process in the correct order, starting with the first step.

The next 3 questions relate to this case study: Exhibits In the event of a reaction or side effect during Ms. Anderson’s chemotherapy session, select the immediate nursing interventions you would take. Select all that apply.

Which information will the nurse consider when deciding what nursing actions to delegate to a licensed practical/vocational nurse (LPN/VN) who is working on a medical-surgical unit?

The following 4 questions pertain to this case study: Exhibits Indicate which nursing interventions the post-surgical unit nurse should complete. (Select all that apply)

Which three nursing interventions can be used to prevent the spread of infection?

A heating pad is ordered for a patient with a lumbar sprain. The nurse knows that the purpose of the heating pad is to:

Which six factors should the nurse consider when choosing a time frame for reassessing the patient’s pain level after implementing pain management?