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 B

Explanation

Choice A reason: Irrigating an NG tube requires sterile technique and assessment of patency, which are beyond the UAP’s scope. This task involves clinical judgment to avoid complications like aspiration, making it inappropriate for delegation.

Choice B reason: Assisting a client to the bathroom post-enema is within the UAP’s scope, involving mobility support and safety. This task does not require clinical judgment beyond ensuring the client’s stability, making it appropriate for delegation.

Choice C reason: Digital removal of stool is an invasive procedure requiring assessment for complications like vagal stimulation or rectal trauma. It is outside the UAP’s scope, as it demands nursing judgment and skill.

Choice D reason: Checking tube feeding aspirate pH and auscultating bowel sounds involve clinical assessment to confirm tube placement and gastrointestinal function. These tasks require nursing expertise and cannot be delegated to a UAP.

A. Monitor for fluid and electrolyte disturbances B. Use standard precautions when caring for the client C. Identify cause of diarrhea and assess bowel habits D. Encourage client to eat small frequent meals

Correct Answer is A

Explanation

Choice A reason: Diarrhea causes significant fluid and electrolyte losses, particularly sodium, potassium, and bicarbonate, risking dehydration and acid-base imbalances. Monitoring these parameters is critical to prevent hypovolemia, arrhythmias, or metabolic acidosis, making it the priority intervention for patient stability.

Choice B reason: Standard precautions are necessary to prevent infection transmission but are a routine practice, not the priority. While important for safety, they do not address the immediate physiological threat of fluid and electrolyte imbalances caused by ongoing diarrhea.

Choice C reason: Identifying the cause of diarrhea and assessing bowel habits is important for long-term management but is secondary to stabilizing the patient. Fluid and electrolyte losses pose an immediate risk, requiring urgent monitoring before diagnostic or historical assessments.

Choice D reason: Encouraging small, frequent meals may help manage diarrhea long-term by reducing gastrointestinal irritation, but it is not the priority. Addressing fluid and electrolyte imbalances takes precedence to prevent life-threatening complications like dehydration or hypokalemia.

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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 task could the RN delegate to the unlicensed assistive personnel (UAP)?

Correct Answer is B

Explanation

A nurse is planning care for a client admitted with diarrhea. Which of the following interventions would be a priority for this client?

Correct Answer is A

Explanation

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

A nurse is caring for a client who has not voided for 8 hours following the removal of an indwelling urinary catheter. Which of the following actions should the nurse take first?

A patient is receiving opioids for pain. Which bowel assessment is a priority?

A nurse assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. A nurse should associate these findings with which of the following types of urinary incontinence?

Which clinical manifestation will the nurse expect to observe in a patient with excessive white blood cells present in the urine?

The nurse is administering ibuprofen (Advil) to an older patient. Which assessment data causes the nurse to hold the medication?

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 nurse is caring for a patient with an ileostomy. Which action by the nurse is most appropriate?