The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?

Review the client's medical history and admission assessment.

Compare the client's current vital signs to the admission baseline.

Note how frequently doses of analgesics have been administered.

Ask the client to describe the intensity of the pain being experienced.

Answer and Explanation

The Correct Answer is D

Choice A reason: While the client's medical history and admission assessment provide valuable information, they do not directly measure the current pain experience.

Choice B reason: Vital signs can indicate pain but are not a definitive measure of pain severity as they can be influenced by other factors.

Choice C reason: The frequency of analgesic administration may suggest the level of pain control but does not measure the current pain intensity experienced by the client.

Choice D reason: Asking the client to describe the intensity of the pain is the most direct and effective way to assess pain severity. Pain is subjective, and the client's self-report is considered the gold standard for pain assessment.

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Correct Answer is D

Explanation

The correct answer is choice D. Paper mask and gown.

Choice A rationale:

The stethoscope is not typically placed in a biohazard bag. It is cleaned and disinfected after each use, especially when used with a patient with an infectious disease like MRSA.

Choice B rationale:

Bed linens are usually placed in a designated linen bag, not a biohazard bag, even when the patient has an infectious disease. The linens are then laundered according to the healthcare facility’s infection control guidelines.

Choice C rationale:

A sputum specimen is typically placed in a designated specimen container, not a biohazard bag. The container is then sent to the lab for analysis.

Choice D rationale:

The paper mask and gown used while caring for a patient with MRSA should be placed in a designated biohazard bag before being removed from the room. This is because these items may have come into contact with the bacteria and could potentially spread the infection.

A. Reduce the amount of pressure being applied on the top of the foot. B. Document in the nurse's notes that the dorsalis pedis pulse is not palpable. C. Obtain a Doppler stethoscope to auscultate the pulse at the same site. D. Palpate the site on the inner side of the ankle below the medial malleolus.

Correct Answer is C

Explanation

Choice A reason: Reducing the amount of pressure may not be effective if the pulse is weak or absent; other methods may be needed to assess circulation.

Choice B reason: Documentation is important, but it should be done after all attempts to assess the pulse have been made.

Choice C reason: Using a Doppler stethoscope is a suitable next step when a pulse is not palpable, as it can detect weaker pulses not felt by palpation.

Choice D reason: Palpating the site on the inner side of the ankle below the medial malleolus assesses the posterior tibial pulse, not the dorsalis pedis pulse.

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The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. When caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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