To assess the quality of the client’s abdominal pain, which approach should the nurse use?

Provide a numeric pain scale.

Ask the client to describe the pain.

Observe body language and movement.

Identify effective pain relief measures.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Providing a numeric pain scale helps quantify the intensity of pain but does not assess the quality of the pain. Quality refers to the characteristics and nature of the pain, which cannot be captured by a numeric scale alone.
Choice B rationale
Asking the client to describe the pain is the best approach to assess the quality of the pain. This allows the client to provide detailed information about the pain’s characteristics, such as its nature, location, and any associated symptoms.
Choice C rationale
Observing body language and movement can provide clues about pain but does not give a comprehensive understanding of the pain’s quality. Nonverbal cues are helpful but should be supplemented with the client’s verbal description.
Choice D rationale
Identifying effective pain relief measures is important for pain management but does not directly assess the quality of the pain. This step comes after understanding the pain’s characteristics.

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Correct Answer is A

Explanation

Choice A rationale
Edema in the fingers and hands can affect the accuracy of a pulse oximeter reading. The swelling can interfere with the probe’s ability to detect the blood flow properly, leading to a falsely low oxygen saturation reading.
Choice B rationale
A capillary refill time of 2 seconds is considered normal and does not typically affect the accuracy of a pulse oximeter reading.
Choice C rationale
Blood pressure of 142/88 mm Hg, while elevated, does not directly impact the accuracy of a pulse oximeter reading.
Choice D rationale
A radial pulse volume of 3+ indicates a strong pulse, which should not interfere with the accuracy of a pulse oximeter reading.

A. Administer a PRN sedative prescription. B. Leave the door to the client’s room open slightly. C. Apply wrist restraints to prevent wandering. D. Provide a back rub at bedtime.

Correct Answer is B

Explanation

Choice A rationale
Administering a PRN sedative prescription should not be the first intervention as it does not address the underlying cause of the client’s confusion and wandering.
Choice B rationale
Leaving the door to the client’s room open slightly can help reduce feelings of isolation and anxiety by allowing the client to see and hear staff members as they pass by.
Choice C rationale
Applying wrist restraints should be a last resort and not the first intervention for managing wandering behavior.
Choice D rationale
Providing a back rub at bedtime may help promote relaxation but does not directly address the issue of wandering.

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To assess the quality of the client’s abdominal pain, which approach should the nurse use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse attaches a pulse oximeter to a client’s finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

Correct Answer is A

Explanation

A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?

Correct Answer is B

Explanation

The nurse assesses an older adult client’s ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client’s posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

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The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a fort?

The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

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