For a client who is crying and seems agitated after major abdominal surgery, which action should a nurse take to establish a nursing diagnosis of pain related to an abdominal incision?

Continue to observe the client.

Ask the client to describe the discomfort.

Encourage the client to progressively relax all muscle groups.

Administer the prescribed analgesic and document the client’s response.

Answer and Explanation

The Correct Answer is B

Ask the client to describe the discomfort. This is the best action to establish a nursing diagnosis of pain related to an abdominal incision because it allows the nurse to assess the location, intensity, quality, and duration of the pain, as well as any factors that aggravate or relieve it.

This information can help the nurse to plan appropriate interventions and evaluate their effectiveness.

Choice A. Continue to observe the client is wrong because it does not address the client’s pain or communicate empathy. The nurse should not ignore or minimize the client’s pain, but rather acknowledge it and offer assistance.

Choice C. Encourage the client to progressively relax all muscle groups is wrong because it is a nonpharmacological intervention that may help to reduce pain, but it does not establish a nursing diagnosis of pain. The nurse should first assess the client’s pain before implementing any interventions.

Choice D. Administer the prescribed analgesic and document the client’s response is wrong because it is a pharmacological intervention that may help to relieve pain, but it does not establish a nursing diagnosis of pain. The nurse should first assess the client’s pain before administering any medications.

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Correct Answer is C

Explanation

This is the priority action because it follows the RACE acronym for fire safety: Rescue, Alarm, Contain, Extinguish. The nurse should first rescue the client from immediate danger by smothering the flames with a blanket.

This will also help contain the fire and prevent it from spreading.

Choice A is wrong because closing the window and removing the client’s oxygen will not put out the fire.

Oxygen is not flammable, but it can make a fire burn faster and hotter. Removing the oxygen source may help reduce the intensity of the fire, but it will not extinguish it.

Choice B is wrong because sounding the fire alarm and activating the emergency response system are important steps, but they are not the priority. The nurse should first ensure the client’s safety before alerting others and calling for help.

Choice D is wrong because removing the client from the room and closing the door may expose the client to more harm and make the fire worse.

The nurse should not move the client unless it is absolutely necessary, as this may cause further injury or infection. Closing the door may create a backdraft, which is a sudden explosion of fire caused by oxygen rushing into an enclosed space.

A. Eyes, ears, lips, and scalp. B. Palms, soles and nails. C. Head, neck and trunk. D. Lower legs and back.

Correct Answer is B

Explanation

Palms, soles and nails.

Melanoma is a type of skin cancer that can develop in any color skin, including dark or black skin.

However, melanoma on dark skin is not related to sun exposure and can start in places that get little sun. That includes the palms of your hands, soles of your feet, nails, and inside your mouth, anal, and genital areas.

Choice A is wrong because eyes, ears, lips, and scalp are not common areas for melanoma in people of color.

Choice C is wrong because head, neck and trunk are more likely to be affected by sun exposure and other types of skin cancer than melanoma in people of color.

Choice D is wrong because lower legs and back are also more exposed to sun and other types of skin cancer than melanoma in people of color.

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For a client who is crying and seems agitated after major abdominal surgery, which action should a nurse take to establish a nursing diagnosis of pain related to an abdominal incision?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse enters a client’s room and finds the client’s gown is on fire. Which is the nurse’s priority action?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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