An older adult man comes to the clinic with a painful rash over his left abdomen. He tells the nurse that he has tried a variety of creams and ointments, but none of them have relieved his symptoms. Which action is most important for the nurse to take?

Place a mask on the client until the cause of the rash is determined.

Determine if the pain was present before the cream was applied.

Question the client about recent exposure to sick children.

Use personal protective equipment while assessing rash.

Answer and Explanation

The Correct Answer is D

Choice A reason: Placing a mask on the client is unnecessary unless the rash is associated with a respiratory pathogen, which is unlikely for an abdominal rash. PPE, like gloves, is critical to protect the nurse from potential infectious causes, such as herpes zoster, ensuring safety during direct assessment of the rash.

Choice B reason: Determining if pain preceded cream application helps identify the rash’s cause but is not the first priority. Using PPE during assessment protects the nurse from infectious rashes, like herpes zoster, which is suggested by the painful, unilateral distribution. Safety during direct contact takes precedence over historical data collection.

Choice C reason: Questioning exposure to sick children may identify infectious causes like varicella but is secondary to nurse safety. A painful abdominal rash suggests herpes zoster, requiring PPE during assessment. Protecting the nurse from potential pathogens during physical examination is the immediate priority before gathering exposure history.

Choice D reason: Using PPE, such as gloves, is critical when assessing a painful abdominal rash, which may indicate herpes zoster, a contagious infection. PPE prevents nurse exposure to infectious agents during direct contact. This action ensures safety, aligning with infection control protocols, especially for unilateral, painful rashes suggestive of shingles.

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Correct Answer is D

Explanation

Choice A reason: The rebound phenomenon, related to cerebellar function, is irrelevant to heating pad application. Heat therapy requires assessing skin sensation to prevent burns. Neurosensory impairment increases burn risk, making sensory assessment critical. Checking for rebound phenomenon does not address the immediate safety concerns of heat application.

Choice B reason: Muscle strength and tone inform mobility or rehabilitation but are not primary concerns for heating pad use. Impaired sensation heightens burn risk, as clients may not feel excessive heat. Sensory assessment takes precedence to ensure safe application, as muscle status does not directly impact heat therapy safety.

Choice C reason: Limitations to range of motion are relevant for mobility but not critical for heating pad safety. Neurosensory impairment increases the risk of burns, as clients may not detect overheating. Sensory assessment ensures the client can report discomfort, making it the priority over joint mobility before applying heat.

Choice D reason: Assessing neurosensory impairment is critical before applying a heating pad, as impaired sensation increases burn risk. Clients with neuropathy or reduced sensation may not feel excessive heat, leading to tissue damage. This assessment ensures safe application, aligning with nursing safety protocols to prevent thermal injury during heat therapy.

A. Tune to a television show or easy listening music to provide distraction. B. Place a hot water circulation device, such as an Aqua K pad, to operative site. C. Provide at least 20 minutes of back massage and gentle effleurage. D. Instruct the client to use guided imagery and slow rhythmic breathing.

Correct Answer is D

Explanation

Choice A reason: Tuning to a television or music may distract from mild pain but is less effective for moderate pain (5/10) post-thoracic surgery. Guided imagery and breathing directly reduce pain perception by calming the nervous system. Distraction is less evidence-based for surgical pain, making it a weaker intervention.

Choice B reason: Applying a hot water device to the operative site risks tissue damage and is contraindicated in acute postoperative settings due to swelling or bleeding risk. Guided imagery and breathing are safer, non-invasive pain relief methods, supported by evidence for reducing surgical pain perception without compromising healing.

Choice C reason: A 20-minute back massage may relax the client but is time-intensive and less targeted for incisional pain. Guided imagery and breathing are more effective, as they directly modulate pain perception via the autonomic nervous system. Massage is secondary, as it may not address the specific surgical pain source.

Choice D reason: Guided imagery and slow rhythmic breathing reduce pain perception by activating the parasympathetic nervous system, lowering stress and enhancing coping. These evidence-based techniques are safe, non-invasive, and effective for moderate postoperative pain (5/10), complementing pharmacological management while awaiting the HCP’s response, supporting client comfort and recovery.

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An older adult man comes to the clinic with a painful rash over his left abdomen. He tells the nurse that he has tried a variety of creams and ointments, but none of them have relieved his symptoms. Which action is most important for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

Correct Answer is D

Explanation

A client who is 2 days postoperative for thoracic surgery is reporting incisional pain 2 hours after receiving pain medication. The client rates the pain as 5 on a 0 to 10 scale. After placing a call to the healthcare provider, which action should the nurse implement?

Correct Answer is D

Explanation

The nurse is planning care for a group of clients during the night shift on a medical unit. Which client should be assessed regularly during the night for sleep apnea?

After reviewing the admission assessment of a client, which intervention(s) should the nurse include in this client’s plan of care? (Select all that apply)

Which intervention should the nurse implement for a client?

Which is the best method for the nurse to use to prepare the skin prior to administration of a topical ointment?

The nurse is caring for a client who wears bilateral hearing aids. Which action should the nurse take when communicating with the client?

An unlicensed assistive personnel (UAP) is asked to answer the call light for a client with streptococcal pharyngitis for whom droplet precautions have been implemented. The UAP refuses, informing the nurse of not being fitted for an N95 respirator mask. Which action should the nurse take?

Which action should the nurse implement for a client with shortness of breath, dyspnea on exertion, and chest pressure?