Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Prior to administering pain medication to an adult postoperative client, what information should the practical nurse (PN) obtain? (Select all that apply.)
A. Height and weight of client prior to admission
Height and weight of client prior to admission are not relevant for administering pain medication and may not affect the dosage or route of the medication.
B. Client's pain rating on a scale of 1 to 10
These are the information that the PN should obtain prior to administering pain medication to an adult postoperative client because they help to assess the client's current pain level, response to previous medication, and need for further intervention. The PN should also document these information in the medical record and report any changes or concerns.
C. Time of last administration of pain medication
These are the information that the PN should obtain prior to administering pain medication to an adult postoperative client because they help to assess the client's current pain level, response to previous medication, and need for further intervention. The PN should also document these information in the medical record and report any changes or concerns.
D. Effectiveness of last pain medication administered
These are the information that the PN should obtain prior to administering pain medication to an adult postoperative client because they help to assess the client's current pain level, response to previous medication, and need for further intervention. The PN should also document these information in the medical record and report any changes or concerns.
E. History of pain medication use during the past year
History of pain medication use during the past year is not relevant for administering pain medication and may not indicate the client's tolerance or preference for the medication
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Exit 2023 Proctored Exam. Take the full exam now
Similar Questions
A nurse is reinforcing teaching with the parents of an infant who has a Pavlik harness.
Which of the following statements should the nurse include in the teaching?
A. "You should place the diaper over the strap of the harness.”
The nurse should not recommend placing the diaper over the strap of the Pavlik harness. Placing the diaper over the strap can cause discomfort and may interfere with the proper function of the harness, which is designed to maintain hip joint alignment in infants with developmental hip dysplasia.
B. "The harness can be removed for sleeping each night.”
The Pavlik harness is typically worn continuously, including during sleep. It should not be removed for sleeping each night because consistent use is essential for its effectiveness in promoting hip joint development.
C. "You can apply lotion under the straps of the harness.”
Applying lotion under the straps of the harness is not recommended. Lotions or creams can create friction and moisture, which may lead to skin irritation or discomfort for the infant. It's best to follow the healthcare provider's instructions regarding the care and maintenance of the harness.
D. "The harness can promote hip joint development.”
The correct choice is D. The nurse should include the statement that "The harness can promote hip joint development" in the teaching. This is because the Pavlik harness is used to treat developmental hip dysplasia by maintaining the hip joint in a stable position, allowing for proper development. It is important for parents to understand the purpose and benefits of the harness in order to ensure compliance and effectiveness of the treatment.
Full Explanation
Choice A rationale:
The nurse should not recommend placing the diaper over the strap of the Pavlik harness. Placing the diaper over the strap can cause discomfort and may interfere with the proper function of the harness, which is designed to maintain hip joint alignment in infants with developmental hip dysplasia.
Choice B rationale:
The Pavlik harness is typically worn continuously, including during sleep. It should not be removed for sleeping each night because consistent use is essential for its effectiveness in promoting hip joint development.
Choice C rationale:
Applying lotion under the straps of the harness is not recommended. Lotions or creams can create friction and moisture, which may lead to skin irritation or discomfort for the infant. It's best to follow the healthcare provider's instructions regarding the care and maintenance of the harness.
Choice D rationale:
The correct choice is D. The nurse should include the statement that "The harness can promote hip joint development" in the teaching. This is because the Pavlik harness is used to treat developmental hip dysplasia by maintaining the hip joint in a stable position, allowing for proper development. It is important for parents to understand the purpose and benefits of the harness in order to ensure compliance and effectiveness of the treatment.
A nurse is reviewing laboratory findings for three clients.
Which of the following laboratory results should the nurse expect for a client who has cirrhosis?
A. Elevated amylase.
Elevated amylase is not typically associated with cirrhosis. Amylase is an enzyme produced by the pancreas and salivary glands, and elevated levels are more commonly associated with pancreatic disorders or acute pancreatitis.
B. Decreased bilirubin.
Decreased bilirubin is not an expected laboratory finding in cirrhosis. Cirrhosis often leads to impaired liver function, which can result in elevated bilirubin levels, causing jaundice.
C. Elevated lipase.
Elevated lipase is not a characteristic laboratory finding in cirrhosis. Lipase is an enzyme produced by the pancreas, and elevated levels are more often seen in pancreatic disorders or acute pancreatitis.
D. Elevated ammonia.
The correct choice is D. Elevated ammonia levels are commonly associated with cirrhosis. In cirrhosis, the damaged liver is unable to effectively metabolize ammonia, leading to its accumulation in the blood. Elevated ammonia levels can result in hepatic encephalopathy, a neurological complication often seen in cirrhotic patients.
Full Explanation
Choice A rationale:
Elevated amylase is not typically associated with cirrhosis. Amylase is an enzyme produced by the pancreas and salivary glands, and elevated levels are more commonly associated with pancreatic disorders or acute pancreatitis.
Choice B rationale:
Decreased bilirubin is not an expected laboratory finding in cirrhosis. Cirrhosis often leads to impaired liver function, which can result in elevated bilirubin levels, causing jaundice.
Choice C rationale:
Elevated lipase is not a characteristic laboratory finding in cirrhosis. Lipase is an enzyme produced by the pancreas, and elevated levels are more often seen in pancreatic disorders or acute pancreatitis.
Choice D rationale:
The correct choice is D. Elevated ammonia levels are commonly associated with cirrhosis. In cirrhosis, the damaged liver is unable to effectively metabolize ammonia, leading to its accumulation in the blood. Elevated ammonia levels can result in hepatic encephalopathy, a neurological complication often seen in cirrhotic patients.
A nurse is assisting with discharge planning for a client who is prescribed home oxygen at 1 to 2 L/min.
The nurse should ensure that the client has which of the following supplies upon discharge?
A. Oxygen mask.
The client does not need an oxygen mask for a low flow rate of 1 to 2 L/min. Oxygen masks are typically used for higher flow rates and may not be comfortable or necessary for a client requiring such a low oxygen flow.
B. Reservoir bag.
A reservoir bag is not required for a client receiving low flow oxygen at 1 to 2 L/min. Reservoir bags are commonly used with oxygen masks at higher flow rates to ensure a consistent supply of oxygen during inhalation.
C. Petroleum jelly.
Petroleum jelly is not a necessary supply for a client prescribed home oxygen at 1 to 2 L/min. Its use may not be recommended due to the risk of flammability in the presence of oxygen.
D. Nasal cannula.
The correct choice is D. The client should have a nasal cannula as a supply upon discharge. A nasal cannula is the appropriate delivery device for low flow oxygen therapy at 1 to 2 L/min. It is comfortable and allows for adequate oxygen supplementation for the client.
Full Explanation
Choice A rationale:
The client does not need an oxygen mask for a low flow rate of 1 to 2 L/min. Oxygen masks are typically used for higher flow rates and may not be comfortable or necessary for a client requiring such a low oxygen flow.
Choice B rationale:
A reservoir bag is not required for a client receiving low flow oxygen at 1 to 2 L/min. Reservoir bags are commonly used with oxygen masks at higher flow rates to ensure a consistent supply of oxygen during inhalation.
Choice C rationale:
Petroleum jelly is not a necessary supply for a client prescribed home oxygen at 1 to 2 L/min. Its use may not be recommended due to the risk of flammability in the presence of oxygen.
Choice D rationale:
The correct choice is D. The client should have a nasal cannula as a supply upon discharge. A nasal cannula is the appropriate delivery device for low flow oxygen therapy at 1 to 2 L/min. It is comfortable and allows for adequate oxygen supplementation for the client.