When caring for clients in pain, the nurse needs to understand that clients:

Will demonstrate vital signs consistent with their intensity of pain

Sometimes complain of pain for no reason

Need to know that the nurse believes what they say about their pain

Who are in pain will request pain medication

Answer and Explanation

The Correct Answer is C

Choice A reason: Vital signs such as heart rate or blood pressure may not consistently reflect pain intensity, especially in chronic pain or in patients with physiological adaptations. Pain is subjective, and relying solely on vital signs can lead to underestimation or mismanagement, as they are not reliable indicators of pain severity.

Choice B reason: Assuming clients complain of pain without reason dismisses the subjective nature of pain. Pain perception varies due to physiological, psychological, or cultural factors. Dismissing complaints risks neglecting underlying conditions like neuropathy or inflammation, undermining trust and effective pain management.

Choice C reason: Acknowledging and believing a client’s pain report fosters trust and effective communication. Pain is a subjective experience, and validation ensures accurate assessment and tailored interventions. This approach aligns with patient-centered care, improving outcomes by addressing individual pain experiences without judgment.

Choice D reason: Not all clients in pain will request medication due to stoicism, fear of addiction, or cultural beliefs. Assuming requests are necessary overlooks silent sufferers, potentially delaying treatment. Nurses must proactively assess pain through verbal and non-verbal cues to ensure timely intervention.

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Correct Answer is C

Explanation

Choice A reason: Bladder distention with tenderness indicates ineffective irrigation, suggesting obstruction or inadequate fluid flow. Continuous bladder irrigation (CBI) aims to maintain bladder patency and prevent clot formation. Distention reflects urine or clot accumulation, potentially leading to bladder injury or infection, requiring immediate intervention.

Choice B reason: Blood clots or sediment in the drainage bag suggest inadequate irrigation. CBI is designed to flush out clots and debris post-surgery to prevent obstruction. Persistent clots indicate the irrigation fluid is not effectively clearing the bladder, increasing risks of catheter blockage and urinary complications.

Choice C reason: Bright red urine turning pink indicates effective CBI. Initially, hematuria is common post-genitourinary surgery, but a lighter color suggests the irrigation is diluting blood and clearing clots, maintaining catheter patency and promoting healing by reducing bladder irritation and obstruction risks.

Choice D reason: Output smaller than the instilled amount suggests fluid retention or leakage, indicating ineffective irrigation. CBI requires output to equal or exceed input to ensure bladder flushing and catheter patency. Reduced output may signal obstruction or absorption, risking bladder overdistention or systemic fluid imbalance.

A. The patient who has a PCA running that needs the syringe replaced. B. The patient who needs to be pre-medicated before walking. C. The patient who is experiencing 8/10 pain and has an immediate order for pain medication D. The patient who needs to take a scheduled dose of maintenance pain medication

Correct Answer is C

Explanation

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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When caring for clients in pain, the nurse needs to understand that clients:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which observation by the nurse best indicates that a continuous bladder irrigation for a patient following genitourinary surgery is effective?

Correct Answer is C

Explanation

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

Correct Answer is C

Explanation

The nurse is caring for different 4 clients. Which of the following client assessments would cause the most concern for the nurse?

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

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?

The nurse anticipates a suprapubic catheter for which patient?

A nurse is providing discharge teaching to a client who will be performing intermittent self-catheterization. Which of the following instructions should the nurse include?

A patient asks about treatment for stress urinary incontinence. Which is the nurse’s best response?

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