Comfort EAQ

Which client assessment finding would the nurse document as subjective data?

1. Blood pressure 120/82 beats/min 2. Pain rating of 5 3. Potassium 4.0 mEq 4. Pulse oximetry reading of 96% Answer: 2 Rationale: Subjective data are obtained directly from a client. Subjective data are often recorded as direct quotations that reflect the client's feelings about a situation. Vital signs, laboratory results, and pulse oximetry are examples of objective data.

Which instruction would the nurse provide to an older client using ice and heat to treat pain from back strain? Select all that apply. One, some, or all responses may be correct.

1. Switch positions every 4 hours. 2.Use a heating pad for the first 24 hours. 3.Apply for 30-minute time intervals. 4.Place the ice pack directly to the injury site. 5.Take ibuprofen every 4 hours PRN. Answer:3 Rationale: To prevent skin damage, ice and heat should only be applied for 20- to 30-minute intervals. Clients should be instructed to shift positions every hour to prevent skin breakdown. Ice should be used for the first 24 to 48 hours followed by heat. Ice should never be directly applied to the skin as it can cause injury to the tissue. The client can take ibuprofen if approved by the health care provider.

The nurse educates the nursing student on measures to reduce vaccine-related pain in children. Which statement by the student indicates a need for further teaching?

1. "I should use a microneedle." 2. "I should apply topical anesthetics." 3. "I should provide tactile stimulation." 4. "I should give antipyretics to the child." Answer: 4 Rationale: According to a research study conducted in Russia, providing analgesics or antipyretics interferes with the immune response produced by the vaccine. Studies also show that providing antipyretics does not help reduce pain and fever caused by vaccination. The use of microneedles reduces pain because this tool is minimally invasive. The application of topical anesthetics to the area before vaccination numbs the area and prevents the perception of pain. Providing tactile stimulation after vaccination helps reduce pain.

Which would the nurse include in the client's medication teaching on the administration of aspirin 650 mg every 6 hours as needed for arthritic pain? Select all that apply. One, some, or all responses may be correct.

1. "Report persistent abdominal pain." 2. "Do not chew enteric-coated tablets." 3. "Take the aspirin with meals or a snack." 4. "See a dentist if bleeding gums develop." 5. "Switch to acetaminophen if tinnitus occurs." Answer: 1,2,3 Rationale: Aspirin therapy may lead to gastrointestinal bleeding, which may be manifested by abdominal pain; if present, the prescriber must be notified immediately. Enteric-coated tablets must not be crushed or chewed. Aspirin is irritating to the stomach lining and can cause ulceration; the presence of food, fluid, or antacids decreases this response. Bleeding gums should be reported to the practitioner, not the dentist. Acetaminophen does not contain the anti-inflammatory properties present in aspirin; tinnitus should be reported to the practitioner.

During an 8-hour shift, a client has a 6-oz (180-mL) cup of tea and 360 mL of water. The client vomits 100 mL, and the instilled intravenous (IV) fluids equaled the urinary output. What is this client's fluid balance at the end of this 8-hour period that the nurse must document on the client's intake and output record?

1. 240 mL 2. -340 mL 3. 440 mL 4. 540 mL Answer: 3 Rationale: 440 mL is the correct calculation. The client's intake was 180 mL of tea and 360 mL of water for a total fluid intake of 540 mL; the client vomited 100 mL, which when subtracted from 540 mL equals 440 mL. The IV fluid intake and the urinary output are equal; therefore they do not influence the final fluid balance. The options 240 mL, -340 mL, and 540 mL are incorrect calculations.

A pediatric client with a past history of chicken pox reports a fever and headache. Which medication would the nurse avoid giving to the client?

1. Aspirin 2. Tetracycline 3.Nalidixic acid 4. Chloramphenicol Answer: 1 Rationale: Clients with a past history of chicken pox should not be administered aspirin because of the risk of the client developing Reye syndrome. Tetracycline generally causes discoloration of the teeth. Nalidixic acid sometimes causes cartilage erosion. Chloramphenicol is associated with Gray syndrome in children.

After surgery, a child experiences intense pain and an analgesic is prescribed. Which would the nurse consider when administering the analgesic?

1. Even though children do not like medicine, analgesics will make them more comfortable. 2.Pain is not felt as strongly by children as by adults; therefore analgesics are not needed as frequently. 3.Children should rarely receive analgesics because they could cause addiction or respiratory depression. 4.Children do not need analgesics because they quickly return to playing or sleeping when they are distracted. Answer: 1 Rationale: Children feel pain and should receive analgesics when needed. The idea that pain is not felt as strongly by children as it is by adults is a myth, although it may be difficult for some children to communicate pain. Not giving analgesics to children is a common but flawed belief and addiction and respiratory depression in children are rare. Some sources suggest that returning to play or sleep is a child's way of coping with unrelieved pain; however, it is no reason to withhold medication.

A client who just returned from a cardiac catheterization reports to the nurse that the pressure bandage on the right groin is tight. Which action would the nurse take?

1. Loosen the dressing slightly. 2.Notify the primary health care provider. 3. Assess the circulatory status of the extremity. 4. Have the client flex the joints of the right leg. Answer: 3 Rationale: Assessing the circulatory status of the extremity will determine whether the dressing is too tight. Loosening the dressing slightly may result in bleeding from the catheter insertion site and is contraindicated. Notifying the primary health care provider is premature; the primary health care provider should be notified if circulation to the leg is compromised. Having the client flex the joints of the right leg may result in bleeding from the catheter insertion site and is contraindicated. The leg should remain extended for several hours.

A client who has a ureteral calculus is admitted to the hospital with severe flank pain, nausea, and hematuria. Which intervention would the nurse implement first?

1. Strain all urine output. 2. Increase oral fluid intake. 3. Obtain a urine specimen for culture. 4. Administer a prescribed analgesic. Answer: 4 Rationale: Pain of renal colic may be excruciating; unless relief is obtained, the client will be unable to cooperate with other therapy. Urine can be saved and strained after the client's priority needs are met. Increasing fluid intake may or may not be helpful. If the stone is large the fluid can build up, leading to hydronephrosis; however, if the stone is small, fluids may help flush the stone. Although a culture generally is prescribed, this is not the priority when a client has severe pain.

Which rational supports administering the medication pregabalin to a client with acquired immunodeficiency syndrome (AIDS)?

1. To reduce neuropathic pain 2. To reduce cognitive difficulty 3. To reduce swallowing difficulty 4. To reduce muscle and joint pain Answer: 1 Rationale: Pregabalin is indicated for neuropathic pain based on its mechanism of interference with nerve signaling. Clients with AIDS generally exhibit emotional and behavioral changes, which can be managed with appropriate antidepressants and anxiolytics. AIDS clients who experience difficulty swallowing may have candidal esophagitis; this condition can be managed with antifungal mediations such as fluconazole or amphotericin B. Traditional analgesics are used to manage joint and muscle pain.