The nurse is caring for an older adult client with a history of osteoarthritis who is having difficulty walking due to increased right knee pain. To assess the quality of the client's knee pain, which approach should the nurse use?

Ask the client to describe the pain.

Observe body language and movement.

Identify effective pain relief measures.

Provide a numeric pain scale.

Answer and Explanation

The Correct Answer is A

Choice A reason: Asking the client to describe the pain is essential as it provides subjective information about the pain's quality, intensity, and impact on daily activities, which is crucial for assessing osteoarthritis pain.

Choice B reason: Observing body language and movement can offer insights into the pain's impact on function, but it does not replace the client's verbal description of the pain experience.

Choice C reason: Identifying effective pain relief measures is part of managing osteoarthritis but does not directly assess the quality of the client's knee pain.

Choice D reason: Providing a numeric pain scale is a method to quantify pain intensity but may not fully capture the quality or characteristics of the pain.

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Correct Answer is A

Explanation

Choice A reason: After cardiac catheterization, monitoring the client's vital signs and telemetry pattern is crucial, especially when symptoms like weakness and dizziness are reported. These symptoms could indicate serious complications such as bleeding, arrhythmia, or cardiac tamponade. Monitoring vital signs can help detect hypotension, hemorrhage, or other hemodynamic instabilities. Telemetry is crucial for detecting arrhythmias that may require immediate intervention.

Choice B reason: Palpating and comparing pedal pulse volumes is an important step to assess for vascular complications such as thrombosis or embolism. However, it is not the immediate priority when a client reports systemic symptoms like weakness and dizziness, which could be signs of more serious conditions.

Choice C reason: Measuring post-procedure intake and output is part of routine postoperative care to ensure proper fluid balance. While important, it is not the most critical action to take when a client is experiencing acute symptoms that could indicate life-threatening complications.

Choice D reason: Removing the dressing and observing the site might be indicated if there is suspicion of bleeding or hematoma formation at the catheterization site. However, since the dressing is reported to be dry and intact, and the client is experiencing systemic symptoms, the priority is to assess for potential systemic complications first.

A. Initiate teaching for client care after discharge. B. Evaluate and update plans of care for clients. C. Begin initial sterile wound care for surgical clients. D. Validate prescribed intravenous flow rates.

Correct Answer is D

Explanation

Choice A reason: Teaching for client care after discharge often involves patient education and planning, which are complex tasks typically reserved for registered nurses due to their scope of practice.

Choice B reason: Evaluating and updating plans of care are responsibilities that involve clinical judgment and are usually performed by registered nurses.

Choice C reason: Initial sterile wound care may require assessment and decision-making that are within the registered nurse's scope of practice.

Choice D reason: Validating prescribed intravenous flow rates is a task that can be delegated to a practical nurse, as it involves monitoring and ensuring that the flow rates are set according to the prescribed orders, which is within the practical nurse's scope of practice.

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The nurse is caring for an older adult client with a history of osteoarthritis who is having difficulty walking due to increased right knee pain. To assess the quality of the client's knee pain, which approach should the nurse use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

One hour following cardiac catheterization via the left femoral site, a client reports feeling weak and dizzy. Assessment reveals that the client's dressing is dry and intact. Which action should the nurse take next?

Correct Answer is A

Explanation

After receiving a change of shift report for clients on a medical-surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

Correct Answer is D

Explanation

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