Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first?
A. Determine the location of the pain.
Determining the location of the pain is the first step in assessing and managing a client's pain. It helps the nurse gather important information about the nature and potential causes of the pain.
B. Administer the medication.
Administering the medication may be necessary, but it should come after the nurse has assessed the location and characteristics of the pain to ensure the correct medication and dosage are given.
C. Reposition the client.
Repositioning the client can be important for comfort and pain relief, but it should come after the nurse has assessed the location of the pain to determine the best position for the client.
D. Review the effects of the pain medication.
Reviewing the effects of the pain medication is important, but it should come after the nurse has administered the medication. It is essential to first address the client's request for pain relief by assessing the pain location and administering the appropriatemedication.
This question is an excerpt from Nurse Dive's nursing test bank - RN Ati fundamental of nursing proctored exam. Take the full exam now
Full Explanation
A. Determining the location of the pain is the first step in assessing and managing a client's pain. It helps the nurse gather important information about the nature and potential causes of the pain.
B. Administering the medication may be necessary, but it should come after the nurse has assessed the location and characteristics of the pain to ensure the correct medication and dosage are given.
C. Repositioning the client can be important for comfort and pain relief, but it should come after the nurse has assessed the location of the pain to determine the best position for the client.
D. Reviewing the effects of the pain medication is important, but it should come after the nurse has administered the medication. It is essential to first address the client's request for pain relief by assessing the pain location and administering the appropriate
medication.
Similar Questions
A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8° C (98.2° F). Which of the following actions should the nurse perform?
A. Hold the client's evening dose of digoxin.
Holding the client's evening dose of digoxin is not the priority at this time. The client's symptoms of confusion and drowsiness require immediate attention to determine the cause.
B. Increase the client's fluid intake.
Increasing the client's fluid intake may be important for various reasons, but it is not the most urgent action in this situation. The client's altered mental status and vital signs need to be assessed first.
C. Complete a neurological check.
Completing a neurological check is the most appropriate action in this situation. The sudden onset of confusion and drowsiness may indicate a neurological issue that needs to be assessed promptly. This includes assessing the client's level of consciousness, pupillary response, motor function, and other neurological signs.
D. Administer the prescribed PRN antihypertensive medication.
Administering the prescribed PRN antihypertensive medication is not indicated based on the client's current presentation. The client's symptoms are more suggestive of a neurological issue rather than hypertension. It's important to address the altered mental status first.
E. Administer the prescribed PRN antihypertensive medication.
Full Explanation
A. Holding the client's evening dose of digoxin is not the priority at this time. The client's symptoms of confusion and drowsiness require immediate attention to determine the cause.
B. Increasing the client's fluid intake may be important for various reasons, but it is not the most urgent action in this situation. The client's altered mental status and vital signs need to be assessed first.
C. Completing a neurological check is the most appropriate action in this situation. The sudden onset of confusion and drowsiness may indicate a neurological issue that needs to be assessed promptly. This includes assessing the client's level of consciousness, pupillary response, motor function, and other neurological signs.
D. Administering the prescribed PRN antihypertensive medication is not indicated based on the client's current presentation. The client's symptoms are more suggestive of a neurological issue rather than hypertension. It's important to address the altered mental status first.
Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use?
A. Ask the client's full name and date of birth.
This is the correct method for identifying the client before administering medication.Asking for the client's full name and date of birth is a standard and effective way to ensure that the right medication is given to the right person.
B. Ask a family member to verify the client's identity.
Depending solely on a family member to verify the client's identity is not considered a reliable method. While involving family members can be helpful in certain situations, the primary responsibility lies with the nurse to directly confirm the client's identity.
C. Verify the client's room number.
Verifying the client's room number is not a sufficient method of client identification.Room numbers can change, and it's possible for clients to be moved, so relying on this alone is not considered safe practice.
D. Check the client's name on the medication administration record (MAR).
Checking the client's name on the medication administration record (MAR) is an important step in medication administration, but it is not the initial method of identifying the client. It's used to confirm that the right medication is being administered to the right person after the client's identity has been established through direct interaction and confirmation.
Full Explanation
A. This is the correct method for identifying the client before administering medication.
Asking for the client's full name and date of birth is a standard and effective way to ensure that the right medication is given to the right person.
B. Depending solely on a family member to verify the client's identity is not considered a reliable method. While involving family members can be helpful in certain situations, the primary responsibility lies with the nurse to directly confirm the client's identity.
C. Verifying the client's room number is not a sufficient method of client identification.
Room numbers can change, and it's possible for clients to be moved, so relying on this alone is not considered safe practice.
D. Checking the client's name on the medication administration record (MAR) is an important step in medication administration, but it is not the initial method of identifying the client. It's used to confirm that the right medication is being administered to the right person after the client's identity has been established through direct interaction and confirmation.
A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive personnel (AP)? (Select all that apply.)
A. Assist a client to ambulate using a gait belt.
This is a correct choice because assisting a client to ambulate using a gait belt is a task that can be delegated to AP, as it does not require clinical judgment or assessment skills.
B. Review a low-sodium diet for a client who has hypertension.
This is an incorrect choice because reviewing a low-sodium diet for a client who has hypertension is a task that requires teaching and evaluation, which are within the scope of practice of the registered nurse (RN) and cannot be delegated to AP.
C. Feed a client who had a stroke 3 months ago.
This is a correct choice because feeding a client who had a stroke 3 months ago is a task that can be delegated to AP, as long as the client does not have dysphagia or other complications that require close monitoring by the RN.
D. Bathe a client who had an amputation 2 days ago.
This is an incorrect choice because bathing a client who had an amputation 2 days ago is a task that requires assessment and intervention by the RN, as the client may have pain, bleeding, infection, or psychological issues related to the amputation.
E. Expllain oral hygiene to a client receiving chemotherapy.
This is an incorrect choice because explaining oral hygiene to a client receiving chemotherapy is a task that requires teaching and evaluation, which are within the scope of practice of the RN and cannot be delegated to AP.
Full Explanation
Rationale A: Assisting a client to ambulate using a gait belt is a task within the scope of practice for assistive personnel. It involves physical support and monitoring, which do not require the advanced training of a registered nurse. This task ensures the client's safety while promoting mobility.
Rationale B: Reviewing a low-sodium diet is not within the scope of practice for assistive personnel as it requires nutritional knowledge and the ability to teach, which are responsibilities of a registered nurse or a dietitian.
Rationale C: Feeding a client who had a stroke 3 months ago can be delegated to assistive personnel. This task does not require the clinical judgment of a nurse and can be performed following a predefined plan of care.
Rationale D: Bathing a client who had an amputation 2 days ago can be delegated to assistive personnel. They are trained to assist with activities of daily living, including bathing, while ensuring the client's safety and comfort.
Rationale E: Explaining oral hygiene to a client receiving chemotherapy involves patient education and understanding of the specific needs related to the client's condition, which are beyond the role of assistive personnel. This task requires the expertise of a nurse or other healthcare professional.