The nurse is caring for a patient from another culture who recently had surgery on their right arm. The patient grimaces every time the nurse tries to assess the right arm, however when asked about their pain level the patient reports, "The pain is not so bad, I can take it. Which of the following should the nurse do next?

Assess the patient for physiological indicators of pain.

Observe the patient for behavior that is indicative of pain.

Involve the patient in the pain assessment by asking more direct questions.

Compare the patient's facial expression to a FACES pain scale.

Answer and Explanation

The Correct Answer is C

A. Assess the patient for physiological indicators of pain. While assessing physiological indicators (such as increased heart rate, blood pressure, or sweating) can provide clues about pain, these signs are not always reliable and can be influenced by other factors. This option does not directly address the patient’s verbal and non-verbal communication about their pain.

B. Observe the patient for behavior that is indicative of pain. Observing the patient’s behavior can be helpful, but it is not sufficient on its own. The patient’s cultural background may influence how they express pain, and relying solely on observation might lead to underestimating their pain.

C. Involve the patient in the pain assessment by asking more direct questions. This is the best option because it respects the patient’s cultural background and encourages a more accurate and detailed assessment of their pain. By asking direct questions, the nurse can gain a better understanding of the patient’s pain experience and provide appropriate care.

D. Compare the patient's facial expression to a FACES pain scale. Using a FACES pain scale can be useful, especially for patients who have difficulty verbalizing their pain. However, this option does not involve the patient in a more detailed discussion about their pain, which is crucial given the cultural context and the patient’s reluctance to openly admit to pain.

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Free Nursing Study Resources

Correct Answer is A, C, B, D

Explanation

Step 1: A. Inject the amount of air into the modified (cloudy) vial that is equal to the prescribed dose of modified (cloudy) insulin. This step is correct and should be done first. Injecting air into the vial of cloudy insulin (modified) helps to prevent creating a vacuum and makes it easier to withdraw the insulin.

Step 3: B. Invert the vial of non-modified (clear) insulin, then insert the needle into the vial and draw back the prescribed dose. This step should be done after air has been injected into the modified insulin vial. The clear insulin (non-modified) should be drawn first to avoid contamination of the clear insulin with the cloudy insulin.

Step 2: C. Inject the amount of air into the nonmodified (clear) vial that is equal to the prescribed dose of nonmodified (clear) insulin. This step should be done before drawing the insulin from the clear vial. Injecting air into the clear insulin vial helps to equalize the pressure and makes it easier to withdraw the insulin.

Step 4: D. Invert the vial of modified (cloudy) insulin, then insert the needle into the vial and draw back the prescribed dose. This step should be done after drawing the clear insulin. Drawing the cloudy insulin last helps to prevent any contamination of the clear insulin with the cloudy insulin.

A. Assess the patient's decision to ensure this is an informed and voluntary choice. B. Tell the patient that this decision is a form of suicide and is not permitted in the hospital. C. Immediately support the patient's wishes by removing food and water from the room. D. Explain to the patient that their feelings are part of the grieving process.

Correct Answer is A

Explanation

A. Assess the patient's decision to ensure this is an informed and voluntary choice. This option ensures that the patient’s choice is informed and voluntary, which is crucial for respecting patient autonomy and making sure that the decision aligns with their wishes and understanding.

B. Tell the patient that this decision is a form of suicide and is not permitted in the hospital. This response dismisses the patient’s feelings and fails to address the underlying issues. It also does not respect patient autonomy or provide compassionate care.

C. Immediately support the patient's wishes by removing food and water from the room. This action might not be appropriate without first ensuring that the decision is informed and voluntary. The patient’s needs and feelings should be fully explored first.

D. Explain to the patient that their feelings are part of the grieving process. This response might minimize the patient’s current experience and needs. While feelings of distress may be part of the process, addressing the patient’s wishes and ensuring informed consent is more crucial.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer prescribed modified (cloudy) and nonmodified (clear) insulin to a client with type 1 diabetes. Place the following steps in the correct order, that the nurse should take to prepare the medication. All options must be used.

Correct Answer is A, C, B, D

Explanation

The nurse is caring for a seriously ill patient with a terminal disease who states, "I do not want to eat anymore, I cannot prolong this agony." Which of the following interventions should the nurse do first?

Correct Answer is A

Explanation

The nurse is admitting a client to the hospital. The client states, "Hospitals make me anxious ever since my last visit. Which of the following would be the most appropriate response by the nurse?

The nurse is discussing the difference between a Do Not Resuscitate (DNR) order and a Allow Natural Death (AND) order to a patient with a terminal illness. Which of the following correctly explains the difference of these two orders?

The nurse is teaching a student nurse how to assist a patient admitted for generalized weakness, to transfer from bed to a chair. The patient has not been out of bed for several days. Which of the following actions by the student nurse requires further teaching?

The nurse is repositioning a patient who has a spinal injury and notes reddened areas on the heels of both feet. The nurse should place the patient in which of the following positions?

The nurse is assessing a group of clients for psychosocial stressors. Which of the following client's should the nurse identify as having this type of stressor?

The nurse is assessing an older adult patient during a regular office visit. The patient reports several symptoms. Which of the following symptoms are not related to the aging process and require further investigation?

The nurse is assessing the vital signs of a sleeping patient at 0400 a.m. and notes the patient is experiencing stage IV non-rapid eye movement (NREM) sleep. The nurse should expect which of the following findings?

The nurse is caring for a client who recently experienced the death of a partner. Which of the following statements would indicate to the nurse that the client is demonstrating appropriate coping strategies?