Which nursing intervention is most effective in determining the severity of a client’s pain?

Compare the client’s current vital signs to the admission baseline.

Review the client’s medical history and admission assessment.

Note how frequently doses of analgesics have been administered.

Ask the client to describe the intensity of the pain being experienced.

Answer and Explanation

The Correct Answer is D

Choice A reason: Comparing vital signs to baseline may show tachycardia from pain-induced sympathetic activation, but this is non-specific, as fever or anxiety can mimic these. Pain is subjective, involving nociceptor signaling, and the client’s direct intensity description provides the most accurate severity measure, guiding targeted treatment.

Choice B reason: Reviewing medical history provides pain context but not current severity. Pain perception involves spinal and cortical nociceptive pathways, and only the client’s description quantifies intensity. Historical data informs diagnosis, but direct assessment is more precise for evaluating present pain, ensuring appropriate analgesic intervention.

Choice C reason: Noting analgesic frequency suggests pain control needs but not current severity. Frequent dosing may indicate tolerance or inadequate relief, not intensity. Pain’s subjective nature, mediated by neural pathways, requires the client’s report to assess severity accurately, guiding dosing over indirect medication usage patterns.

Choice D reason: Asking the client to describe pain intensity directly captures their subjective experience, mediated by nociceptors and cortical perception. Using a 0–10 scale quantifies severity, guiding precise analgesia. This is most effective, as pain is personal, ensuring accurate assessment and tailored treatment to alleviate discomfort effectively.

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Correct Answer is B

Explanation

Choice A reason: Positioning the sterile field at hip level maintains sterility but is not specific to uncircumcised clients. Cleaning the meatus before retracting the foreskin prevents infection by removing bacteria first. This is secondary, per infection control and catheterization procedure standards in nursing practice.

Choice B reason: Cleaning the meatus before retracting the foreskin removes bacteria, reducing infection risk in uncircumcised clients. This sequence ensures sterility before exposing sensitive areas, critical for preventing urinary tract infections, per evidence-based catheterization and infection control protocols in urological nursing care.

Choice C reason: Wiping the meatus in backward strokes is incorrect, as circular strokes from meatus outward are standard to avoid contamination. Cleaning before retracting the foreskin is critical for infection prevention. This violates sterile technique, per catheterization and infection control standards in nursing.

Choice D reason: Advancing the catheter before inflating the balloon is standard but not specific to uncircumcised clients. Cleaning the meatus first addresses foreskin-related infection risks. Balloon inflation timing is universal, per indwelling catheter insertion and urological care protocols in nursing practice.

A. Blood pressure is 142/88 mm Hg. B. 2+ edema of fingers and hands. C. Radial pulse volume is 3+. D. Capillary refill time is 2 seconds.

Correct Answer is B

Explanation

Choice A reason: Blood pressure of 142/88 mm Hg indicates mild hypertension but does not directly affect pulse oximetry, which measures arterial oxygen saturation via hemoglobin light absorption. Hypertension does not typically cause hypoxemia (91% SpO₂). Edema is more likely, as it disrupts sensor accuracy, leading to false low readings.

Choice B reason: 2+ edema in fingers and hands impairs pulse oximeter accuracy, as fluid in tissues scatters light, reducing the sensor’s ability to detect arterial hemoglobin saturation. This causes falsely low SpO₂ readings (91%), common in edema from heart failure, making it the primary contributor to the inaccurate measurement.

Choice C reason: A radial pulse volume of 3+ indicates strong arterial flow, supporting accurate pulse oximetry by ensuring perfusion. This does not explain a low SpO₂ of 91%, as strong pulses enhance sensor reliability. Edema’s interference with light transmission is more likely to cause the reduced reading.

Choice D reason: Capillary refill of 2 seconds is normal, indicating adequate perfusion. This does not contribute to a low SpO₂ (91%), as pulse oximetry measures arterial flow, not capillary dynamics. Edema disrupts light transmission, causing inaccurate readings, making it the most likely cause of the observed saturation.

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Which nursing intervention is most effective in determining the severity of a client’s pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which action should the nurse implement when inserting an indwelling catheter for an uncircumcised male client?

Correct Answer is B

Explanation

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 B

Explanation

After a client voids, 150 mL of residual urine is measured. Which nursing problem should be included in this client’s plan of care?

The nurse is initiating a 24-hour urine collection for a client with an indwelling urinary catheter. After emptying all the urine from the collection bag, which action is most important for the nurse to implement?

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