Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assisting with the care of a client who is receiving a PCA pump following a hysterectomy. Which of the following findings should the nurse identify as an indicator of unrelieved pain?
A. Clenched teeth
Clenched teeth are a sign of unrelieved pain and indicate that the client needs more analgesia from the PCA pump. Difficulty swallowing, constipation, and urinary retention are common side effects of opioids and do not necessarily indicate unrelieved pain.
B. Difficulty swallowing
C. Constipation
D. Urinary retention
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Proctored Exam. Take the full exam now
Full Explanation
The correct answer is A.
Clenched teeth are a sign of unrelieved pain and indicate that the client needs more analgesia from the PCA pump. Difficulty swallowing, constipation, and urinary retention are common side effects of opioids and do not necessarily indicate unrelieved pain.
Similar Questions
A nurse is reinforcing teaching with a new mother about facility security measures. Which of the following statements by the mother indicates an understanding of the teaching?
A. I will have an identification band that matches the one my baby wears."
The mother and the baby should have matching identification bands to prevent abduction or mix-up.
B. I can remove my security band to give it to a family member."
The mother should not remove her security band, as this can compromise her identity and safety.
C. I can take my baby to the lobby to visit family."
The mother should not take her baby to the lobby or other public areas, as this can expose the baby to infection or harm.
D. "I will carry my baby to the nursery."
The mother should use a bassinet or crib to transport her baby to the nursery, as this can prevent falls or injuries.
Full Explanation
The mother and the baby should have matching identification bands to prevent abduction or mix-up.
The mother should not remove her security band, as this can compromise her identity and safety.
The mother should not take her baby to the lobby or other public areas, as this can expose the baby to infection or harm.
The mother should use a bassinet or crib to transport her baby to the nursery, as this can prevent falls or injuries.
A nurse is administering a client's morning oral medications. Which of the following actions should the nurse take?
A. Identify the client by using one identifier before giving the medication.
B. Document medication administration prior to administering medication.
C. Administer time-critical medication 60 min before or after the scheduled time.
D. Verify the medication three times with the medication administration record.
Verify the medication three times with the medication administration record. The nurse should follow the six rights of medication administration: right client, right drug, right dose, right route, right time, and right documentation. To ensure the right drug and dose, the nurse should check the medication label against the medication administration record (MAR) three times: before removing the medication from the storage area, before preparing or measuring the medication, and before administering the medication to the client. The nurse should also use two identifiers (such as name and date of birth) to verify the right client. The nurse should document medication administration after giving the medication, not before, to avoid errors and ensure accuracy. The nurse should administer time-critical medications within 30 minutes before or after the scheduled time, not 60 minutes.
Full Explanation
The correct answer is D.
Verify the medication three times with the medication administration record. The nurse should follow the six rights of medication administration: right client, right drug, right dose, right route, right time, and right documentation. To ensure the right drug and dose, the nurse should check the medication label against the medication administration record (MAR) three times: before removing the medication from the storage area, before preparing or measuring the medication, and before administering the medication to the client.
The nurse should also use two identifiers (such as name and date of birth) to verify the right client. The nurse should document medication administration after giving the medication, not before, to avoid errors and ensure accuracy. The nurse should administer time-critical medications within 30 minutes before or after the scheduled time, not 60 minutes.
A nurse is reinforcing discharge teaching with a client who has undergone a vein stripping of the right leg. Which of the following instructions should the nurse include in the teaching?
A. Maintain bed rest for 48 hr.
The client should not maintain bed rest, as this can increase the risk of thrombosis and infection.
B. Keep legs in a dependent position.
The client should elevate the leg above the heart level, not keep it in a dependent position, as this can reduce venous pressure and edema.
C. Wrap the leg with an elastic bandage.
The client should wrap the leg with an elastic bandage to reduce swelling and promote healing.
D. Implement a sodium-restricted diet.
The client does not need to implement a sodium-restricted diet, as this is not related to vein stripping.
Full Explanation
The client should wrap the leg with an elastic bandage to reduce swelling and promote healing.
The client should not maintain bed rest, as this can increase the risk of thrombosis and infection.
The client should elevate the leg above the heart level, not keep it in a dependent position, as this can reduce venous pressure and edema.
The client does not need to implement a sodium-restricted diet, as this is not related to vein stripping.