Pain/vs/ surgical client

A nurse is assisting with a staff in-service regarding pain control. Which of the following statements by a staff member indicates an understanding of the information? (Select all that apply.)

"A client's religious beliefs might affect the way they respond to pain.""The client's past pain experiences are not related to their current pain and pain management.""Pain control might be harder to achieve if the nurse and client speak different primary languages."

A Charge nurse is reviewing orthostatic hypotension with a group of newly licensed nurses. which of the following should charge nurse make?

"A decrease of 20 mmHg in systolic pressure with the position change indicate orthostatic hypotension"

A nurse is evaluating a client's pain level using the PQRST mnemonic. Which of the following questions should the nurse ask to evaluate the letter "R"?

"Can you point to where you are having your pain?"

A charge nurse is providing an in-service for a group of nurses about cardiac output. Which of the following statements should the nurse include?

"Cardiac output is the amount of blood flow through the heart in 1 minute."

A nurse is providing teaching about thermoregulation to a group of newly licensed nurses. Which of the following statements should the nurse include in the teaching?

"The body lowers body temperature through sweating

a charge nurse is reviewing the technique for obtaining SaO2 with a group of newly hired nurses. Identify the order of steps the nurse should include

1st- Select a site for obtaining the measurement 2nd- apply the sensor pro on chosen site 3rd- Confirm the pulse rate displayed an oximeter by palpating the radio pause 4th- wait 15 seconds to obtain the SaO2 Percent age Display on the pulse oximeter

A nurse is reviewing the recent vital signs of a group of clients. Which of the following clients should the nurse see first?

A 52-year-old client who has an SaO2 of 92%

A nurse is caring for a client who is experiencing tachypnea due to an exacerbation of asthma. Which of the following medications should the nurse anticipate administering?

A bronchodilator

A nurse working on a medical-surgical unit is caring for a group of clients. Which of the following clients' vital signs should the nurse identify is outside the expected reference range and notify the provider

A client who has an apical pulse rate of 120/min

A nurse is planning care for a group of clients and is delegating to the assistive personnel (AP) to take the clients' vital signs. For which of the following clients should the nurse obtain the vital signs rather than the AP?

A client who was recently admitted and reports chest pain

A nurse is preparing an in-service about peripheral pulses for a group of staff nurses. Which of the following information should the nurse include?

A pulse strength of +1 indicates that the pulse is weak or diminished upon palpation.

A nurse is collecting data from a client who is preoperative for a surgical procedure. Which of the following information should the nurse document in the client's medical record? (Select all that apply.)

Allergies Alcohol use Spiritual beliefs

A nurse is assisting in developing a plan to manage a client's perioperative pain. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

Ask the client what interventions they prefer Determine how the client has responded to analgesics in the past Include nonpharmacological methods to reduce pain

A nurse is reinforcing teaching provided to a client about postoperative complications. Which of the following should the nurse identify as creating a risk for the client to develop pneumonia?

Aspiration

A nurse is collecting data on a client who is postoperative following a hip arthroplasty. Which of the following findings is a possible manifestation of bleeding?

Blood pressure 88/60 mm Hg

A nurse is reviewing the plan of care for several clients who are receiving treatment for pain. Which of the following actions should the nurse plan to take to evaluate the clients' pain control? (Select all that apply.)

Consider each client's cultural preferences.Determine the effectiveness of nonpharmacological strategies.Use a pain scale specific to each client's cognitive abilities.

A nurse is caring for a client who has hypotension. Which of the following factors should the nurse identify as a contributing factor to the client's condition?

Decrease in contractility

A nurse is assisting with the care of client who has orthostatic hypotension. Which of the following actions should the nurse take?

Encourage the client to change position slowly

A nurse is contributing to the plan of care for a client who is experiencing TACHYCARDIA. Which of the following should the nurse plan to recommend

Encourage the client to practice relaxation techniques each day.

A nurse is caring for a client who has a heart rate of 118/min. Which of the following actions should the nurse take to improve the client's heart rate?

Encourage the client to reduce intake of caffeinated soft drinks.

A nurse is discussing end-of-life pain management with a group of coworkers. Which of the following should the nurse include as barriers to end-of life pain management? (Select all that apply.)

Fear of addictionBelief that pain is an expected part of their illnessInadequate pain assessment

a nurse is contributing tp the planning of an in-service about factors-affecting respiratory rate for a group of assistive personnel. Which of the following info should the nurse recommend be included?

Fever can increase a client's respiratory rate.

A charge nurse is reviewing the expected reference range of blood pressure in adult clients with a newly licensed nurse. Which of the following statements should the charge nurse include?

Hypertension is diagnosed with two elevated measurements on two separate occasions."

A nurse is caring for a client who has an increase in cardiac output. Which of the following findings should the nurse expect?

Increase in blood pressure

A nurse is providing care to a client who has an apical pulse rate of 54/min and is experiencing dizziness. Which of the following is the nurse's priority action?

Inform the client to ask for assistance with getting out of bed.

A nurse is planning postoperative care for a client. Which of the following actions should be the nurse's priority?

Monitor the client's oxygen saturation.

A nurse obtains a client's electronic blood pressure reading of 188/96 mm Hg. Which of the following actions should the nurse take next? Obtain a manual blood pressure reading from the client.

Obtain a manual blood pressure reading from the client.

A nurse is caring for a client who has a prescription for oxycodone 5 to 10 mg PO every 4 to 6 hr as needed for pain rating 7 to 10 on a 0 to 10 scale. Fifteen minutes after receiving the dose, the client reports to the nurse their pain is still a 7 and has not changed. Which of the following actions should the nurse take?

Offer to assist the client with nonpharmacological relief strategies.

A nurse is reviewing documentation of vital signs by a newly licensed nurse for an assigned client. Which of the following entries in the chart requires follow up by the nurse?

Pulse rate 116/min, left radial, standing, immediately following 10 min of ambulating in hall.

A nurse is collecting data on a client who is postoperative following abdominal surgery. Which of the following findings is a manifestation of an infection?

Redness around the incision site

A nurse is caring for a client who asks about factors that could cause their pulse rate to increase. Which of the following factors should the nurse include in their response?

Smoking

A charge nurse is reviewing factors that can affect a client's perception of pain with a newly licensed nurse. Which of the following should the charge nurse include? (Select all that apply.)

Stress Culture Social support Disease severity

A nurse is observing an assistive personnel (AP) who is obtaining a blood pressure reading from a client. Which of the following actions by the AP requires follow up by the nurse?

The AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second.

A nurse is assessing the surgical wound of a postoperative client. Which of the following information should the nurse include in the documentation of the wound? (Select all that apply.)

The client states the wound is painful. The edges of the wound are red is correct. The client has a fever.

A nurse is collecting data on a client who is preparing for discharge following surgery. Which of the following findings should be the nurse's priority concern?

The client takes medications that cause dizziness.

A nurse is discussing cutaneous stimulation with a client who has back pain. Which of the following methods should the nurse include? (Select all that apply.)

Transcutaneous electronic stimulating unit (TENS unit) Massage Acupuncture Cold therapy

A nurse is is discussing oxygen saturation with a client. Which of the following information should the nurse include?

oxygen saturation reflects the amount of oxygen being delivered to the body tissue