The nurse is administering pain medication for several patients. Which patient does the nurse administer medication to first?

The patient who has a PCA running that needs the syringe replaced.

The patient who needs to be pre-medicated before walking.

The patient who is experiencing 8/10 pain and has an immediate order for pain medication

The patient who needs to take a scheduled dose of maintenance pain medication

Answer and Explanation

The Correct Answer is C

Choice A reason: Replacing a PCA syringe ensures continued pain control but is less urgent than acute severe pain. PCA systems often have residual medication, allowing a brief delay without compromising pain management, so this is not the priority.

Choice B reason: Pre-medicating before walking prevents pain exacerbation but is less critical than addressing existing severe pain. Scheduled mobility can be delayed slightly to prioritize acute needs, making this a lower priority intervention.

Choice C reason: A patient with 8/10 pain and an immediate order indicates acute, severe distress requiring urgent intervention. Severe pain can elevate stress hormones, heart rate, and blood pressure, necessitating prompt medication to stabilize the patient and alleviate suffering.

Choice D reason: Scheduled maintenance medication maintains baseline pain control but is not urgent compared to acute 8/10 pain. Delaying a scheduled dose briefly is less likely to cause harm than untreated severe pain, making this a lower priority.

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Correct Answer is D

Explanation

Choice A reason: Wiping from back to front risks introducing perianal bacteria into the urethra, contaminating the sample. Proper technique involves wiping front to back to minimize contamination, making this statement incorrect and indicative of misunderstanding.

Choice B reason: While menstruation may complicate urine collection, it is not an absolute contraindication. With proper technique (e.g., using a tampon), samples can be collected. This statement reflects a misconception and does not confirm understanding of midstream collection.

Choice C reason: Urine should be sent to the lab promptly or refrigerated to prevent bacterial growth or analyte degradation. Allowing it to cool to room temperature risks inaccurate results, so this statement demonstrates a lack of understanding of proper handling.

Choice D reason: Urinating a small amount into the toilet first flushes out urethral contaminants, ensuring a cleaner midstream sample. This technique is critical for accurate urinalysis or culture, confirming the client’s understanding of the taught procedure.

A. Take the client to the bathroom every 2 hr. B. Request a prescription for an indwelling urinary catheter C. Remind the client to tell the nurse when he has to urinate. D. Use adult diapers to prevent frequent clothing changes.

Correct Answer is A

Explanation

Choice A reason: Scheduled toileting every 2 hours establishes a routine, compensating for dementia-related cognitive deficits in recognizing bladder cues. This promotes continence, reduces accidents, and maintains dignity, making it the most effective behavioral intervention.

Choice B reason: Indwelling catheters increase risks of urinary tract infections, skin breakdown, and discomfort, especially in dementia patients unable to communicate issues. They are a last resort, not appropriate for managing incontinence without medical necessity.

Choice C reason: Reminding a dementia patient to report urination needs is ineffective, as cognitive impairment limits their ability to recognize or communicate bladder signals. This approach does not address the underlying issue of incontinence.

Choice D reason: Adult diapers manage accidents but do not promote continence or address the behavior. They may reduce dignity and increase skin breakdown risk, making scheduled toileting a more proactive and dignified intervention.

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The nurse is administering pain medication for several patients. Which patient does the nurse administer medication to first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is instructing a female client on obtaining a midstream urine specimen. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

Which clinical manifestation will the nurse expect to observe in a patient with excessive white blood cells present in the urine?

The patient is having lower abdominal surgery and the nurse inserts an indwelling catheter. What is the rationale for the nurse’s action?

Which of the following client statements would cause the nurse to further question the client?

The nurse is caring for patients with ostomies. In which ostomy location will the nurse expect very liquid stool to be present?

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A nurse is obtaining a 24-hour urine specimen collection from the patient. Which action should the nurse take?

A patient is being seen for complaints of severe flank pain lasting for 2 days. The emergency department physician suspects that the patient has renal calculi. Which of the following tests would the nurse expect the health care provider to order?

A patient expresses concerns over having black stool. The fecal occult blood test is negative. Which response by the nurse is most appropriate?