Which assessment is most important for the nurse to perform prior to the application of a heating pad?

Limitations to range of motion.

Muscle strength and tone.

Degree of neurosensory impairment.

Presence of rebound phenomenon.

Answer and Explanation

The Correct Answer is C

Choice A: Limitations to range of motion are not directly related to the application of a heating pad. A heating pad may help reduce pain and stiffness, but it does not affect the range of motion itself.

Choice B: Muscle strength and tone are also not directly related to the application of a heating pad. A heating pad may relax tense muscles, but it does not affect the strength or tone of the muscles.

Choice C: Degree of neurosensory impairment is the most important assessment for the nurse to perform prior to the application of a heating pad. A heating pad can cause burns or tissue damage if the patient has impaired sensation and cannot feel the heat or pain. The nurse should check the patient's ability to perceive temperature, pressure, and pain before applying a heating pad.

Choice D: Presence of rebound phenomenon is not relevant to the application of a heating pad. Rebound phenomenon refers to the worsening of symptoms after discontinuing a medication or treatment. A heating pad does not cause rebound phenomenon.

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Correct Answer is A

Explanation

Choice A Reason: This is correct because fluid volume deficit is a life-threatening condition that can result from diarrhea and fecal incontinence. The nurse should monitor the client's fluid intake and output, electrolytes, weight, urine specific gravity, and skin turgor.

Choice B Reason: This is incorrect because bowel incontinence is a significant problem that can affect the client's dignity, comfort, and skin integrity, but it is not as urgent as fluid volume deficit. The nurse should implement a bowel management program and provide appropriate hygiene and skin care.

Choice C Reason: This is incorrect because caregiver role strain is a potential problem that can affect the parent's well-being and ability to provide care, but it is not as critical as fluid volume deficit. The nurse should assess the parent's coping skills, support system, and respite needs.

Choice D Reason: This is incorrect because impaired bed mobility is a chronic problem that can affect the client's functional status and quality of life, but it is not as serious as fluid volume deficit. The nurse should assist the client with positioning, turning, transferring, and exercising.

A. One ounce medicine cup. B. 3 mL syringe and a sterile needle. C. 3 mL syringe. D. Tuberculin syringe.

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because a one ounce medicine cup is not precise enough to measure a 5 mL dose of viscous liquid solution. A one ounce medicine cup can hold about 30 mL of liquid, which is too large for a small dose.

Choice B Reason: This is incorrect because a 3 mL syringe and a sterile needle is not appropriate for oral administration of medication. A needle may cause injury to the oral mucosa or the esophagus.

Choice C Reason: This is correct because a 3 mL syringe can measure a 5 mL dose of viscous liquid solution accurately and safely. A syringe can draw up the solution easily and deliver it to the mouth without spilling or dripping.

Choice D Reason: This is incorrect because a tuberculin syringe is too small to measure a 5 mL dose of viscous liquid solution. A tuberculin syringe can hold only 1 mL of liquid, which is not enough for the required dose.

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Which assessment is most important for the nurse to perform prior to the application of a heating pad?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse identifies several nursing problems for a client with paraplegia who has been having fecal incontinence and diarrhea. The client's parent is the primary caregiver. In planning care, the nurse should determine which problem is the highest priority?

Correct Answer is A

Explanation

Which equipment should the nurse use to measure a 5 mL dose of viscous liquid solution most accurately to be administered orally?

Correct Answer is C

Explanation

While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, solid, and light brown. Which action should the nurse implement?

A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?

A client who had surgery 3 days ago is sitting with head of bed at 75 degrees and requests to be repositioned. Which instruction is most important for the nurse to provide to the unlicensed assistive personnel (UAP)?

The nurse observes a decrease in a client's level of consciousness. Which vital sign should the nurse obtain first?

The nurse observes the unlicensed assistive personnel (UAP) securing a client’s wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. While caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?

The nurse is teaching a client about use of the syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

After reviewing the admission assessment of a client with chronic pain, which intervention(s) should the nurse include in this client's plan of care? (Select all that apply.)