Comfort Level 2

A nurse is educating a client who is experiencing sleep disturbances and desires to decrease caffeine intake. Which of the following beverages should the nurse recommend?

lemon-lime soda

A nurse is providing teaching to a client who has a new diagnosis of fibromyalgia. Which of the following client statements indicates an understanding of the teaching?

low impact aerobics can help reduce episodes of pain

A nurse is caring for a client who has diverticular disease. When palpating the client's abdomen, in which of the following locations should the nurse expect the client to report abdominal pain?

lower left quadrant

A nurse is caring for a client who is menopausal and asks the nurse about the use of herbal therapies to reduce her discomfort. Which of the following statements should the nurse make?

many herbal products have not undergone long term testing for safety and efficacy

A nurse is caring for a client who is taking aspirin for arthritis. The nurse should identify which of the following findings as an adverse effect of this medication?

tinnitus

A nurse is monitoring a client who took an overdose of acetaminophen 72 hr ago. The nurse should identify which of the following findings as a manifestation of acetaminophen poisoning?

vomiting

A nurse is teaching a client who has fibromyalgia syndrome about measures to reduce the occurrence of symptoms. Which of the following interventions should the nurse include in the teaching?

Establish a regular sleep pattern

A nurse is assessing a client 1 day postoperative following abdominal surgery. Suddenly the client reports a pulling sensation and pain in his surgical incision. Which of the following actions should the nurse take?

Cover the area with saline-soaked sterile dressings

A nurse in the emergency department is caring for a client who comes to the emergency department reporting severe abdominal pain in the left lower quadrant. The provider suspects a ruptured ectopic pregnancy. Which of the following signs indicates to the nurse that the client has blood in the peritoneum?

Cullen's sign

A nurse is caring for a 6-month-old infant. Which of the following findings should indicate to the nurse that the client is experiencing pain following a procedure?

Increased crying episodes

A nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following actions should the nurse take when applying the pad?

Stop the treatment if the client's skin becomes red

A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make?

"A headache is an expected adverse effect of the medication."

A nurse is teaching a client about the uses of chamomile. Which of the following information should the nurse include in the teaching?

"Chamomile may act as a calming agent."

A nurse is assessing a client who has insomnia. Which of the following questions is the highest priority for the nurse to ask the client?

"Do you have difficult staying awake when you are driving?"

A nurse is preparing a presentation about ginkgo biloba to a group of clients. Which of the following information should the nurse include in the teaching?

"Ginkgo biloba can reduce feelings of restlessness."

A nurse is teaching a client who has a new prescription for colchicine to treat gout. Which of the following instructions should the nurse include?

"Monitor for muscle pain" This medication can cause rhabdomyolysis. The client should monitor and report muscle pain.

A nurse is teaching a client who has a new prescription for codeine. Which of the following instructions should the nurse include in the teaching?

"You should change positions slowly."

A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)

An increase in neutrophils Localized edema

A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first?

Determine the location of the pain

A nurse is teaching a client who is to begin medicated treatment of tuberculosis. The nurse should instruct the client that which of the following herbal supplements can interact adversely with the treatment?

Echinacea

A nurse is caring for a client who is to start therapy with ibuprofen for hip pain. Which of the following information should the nurse provide about ibuprofen?

Take the medication with food

A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take?

apply an ice pack to the affected area

A nurse is caring for a client who is beginning to breastfeed her newborn after delivery. The new mother states, "I don't want to take anything for pain because I am breastfeeding." Which of the following statements should the nurse make?

"We can time your pain medication so that you have an hour or two before the next feeding."

A nurse is caring for a client who has rheumatoid arthritis and tells the nurse that she wears a copper bracelet to help her feel better. Which of the following responses should the nurse make?

"Yes, I understand that you feel better wearing your bracelet." - The nurse illustrates the therapeutic communication technique of accepting. The nurse demonstrates the knowledge that the bracelet is harmless for the client and shows respect for the client's beliefs.

A nurse is talking to a client who is taking a calcium supplement for osteoporosis. The client tells the nurse she is experiencing flank pain. Which of the following adverse effects should the nurse suspect?

renal stones

A nurse is assessing a client's abdomen who reports stomach pain. Which of the following actions should the nurse take first?

to inspect

A charge nurse is supervising a newly licensed nurse provide care for a client who has a PCA pump. Which of the following statements made by the nurse requires further action by the charge nurse?

"I discarded the remaining 2 milligrams of morphine from the PCA pump. Please document that you witnessed it."

A nurse is providing teaching to a client who has gout and a new prescription for allopurinol. Which of the following statements by the client indicates an understanding of the teaching?

"I need to increase my fluid intake while taking this medication."

A nurse is teaching a client who is perimenopausal and has recurrent lower back pain. Which of the following client statements indicates an understanding of the teaching?

"I should keep my weight within 10 percent of my ideal weight."

A nurse is caring for a client who is using a patient-controlled analgesia (PCA) pump for postoperative pain management. The nurse enters the room to find the client asleep and his partner pressing the button to dispense another dose. Which of the following responses should the nurse make?

"Your husband should decide when more medication is needed."

A nurse is providing teaching to a client who takes opioid pain medication and has a new prescription for docusate sodium. Which of the following statements by the client indicates an understanding of the teaching?

"It might take up to 3 days for the medication to work."

A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

"It's unfortunate that I have to be in the hospital for this treatment."

A nurse is teaching a client who has bipolar disorder about lithium. Which of the following statements should the nurse include in the teaching?

"Notify your provider if you experience vomiting or diarrhea." - Vomiting and diarrhea are both manifestations of lithium toxicity and should be reported to the provider. Vomiting and diarrhea can also cause dehydration, which can result in lithium toxicity.

A nurse is teaching a client about how to use a patient-controlled analgesia (PCA) pump. Which of the following instructions should the nurse include in the teaching?

"use the pain scale to determine if you need to self-administer."

A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which of the following actions should the nurse take? (Select all that apply.)

-Offer the client a back rub -Remind the client to use incisional splinting -Identify the client's pain level -Change the client's position

A nurse is assessing a client who has narcolepsy. Which of the following findings should the nurse expect? (Select all that apply).

-Sudden attacks of sleep -Hallucinations at the onset of sleep

A nurse is preparing to administer meperidine 35 mg IM to a client every 6 hr PRN for pain. Available is meperidine injection 75 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.5 mL

A nurse is preparing to administer meperidine 75 mg IM to a client who reports postoperative pain. Available is meperidine 100 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.8 mL

A nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take? (Select all that apply.)

Check on the client hourly Instruct the client in the use of the call light Apply an ambulation alarm to the client's leg

A nurse is preparing to administer gabapentin 900 mg PO once daily for a client who has neuropathic pain. The amount available is gabapentin 300 mg/capsule. How many capsules should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

3 capsules

A nurse is caring for a client is receiving hydromorphone HCL via PCA pump and reports continuous pain of 6 on a scale from 0 to 10. Which of the following actions should the nur! take first?

Check the display on the PCA pump

A nurse is planning care for a client who is postoperative. Which of the following statements about pain management should the nurse consider when implementing client care? (Select all that apply.)

?

A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection. Which of the following client statements indicates an understanding of pain control?

A. "I will call for pain medication before the previous dose wears off."

A community health nurse is preparing a presentation about complementary and alternative therapies. Which of the following therapies should the nurse describe as a means of manipulating a series of channels to re-establish the flow of vital energy within the body?

Acupuncture

A nurse is caring for a toddler who is 24 hr postoperative following a cleft palate repair. Which of the following actions should the nurse take?

Administer opioids for pain

A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take?

Apply the bag for 30 min at a time.

A nurse is coaching four clients in the use of relaxation techniques to manage stress. Which of the following findings indicate the techniques are effective? (Select all that apply.)

Arousal reduction Decreased BP Decreased HR Increased peripheral skin temperature

A nurse is caring for a client who is 1 day postoperative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first?

Ask the client to rate her pain on a scale from 0 to 10.

A nurse is applying a cold compress for a client who has pain and minor swelling in a sutured laceration on the forearm. Which of the following assessments should the nurse use to determine whether the treatment is effective?

Asking the client to rate the pain

A nurse is planning care for a client who is 4 hr postoperative. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

Assist the client to cough & dee breathe every hour Administer PRN analgesics as needed Give the client a back massage Teach the client relaxation techniques

A nurse is preparing a presentation at a community center about complementary and alternative therapies. Which of the following therapies should the nurse describe as programming the mind to override the stress response?

Autogenic training

A nurse is educating coworkers about how to minimize back strain and avoid repeated episodes of low back pain. Which of the following strategies should the nurse include? (Select all that apply.)

Avoid prolonged sitting Sleep in side-lying position with flexed knees Try padded shoe insoles

A nurse is preparing a presentation at a community center about complementary and alternative therapies. Which of the following therapies should the nurse describe as the use of an electronic monitoring device to help clients learn to control physical responses to stress?

Biofeedback

A nurse is caring for a 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take?

Encourage the parents to rock the infant

A nurse is caring for a client who reports bilateral knee pain after hiking this past weekend in the mountains on rough ground. He says he is concerned because his cousin died from bone cancer recently. Which of the following actions should the nurse take?

Explain that the provider will see him and determine a course of action. - This response illustrates the therapeutic communication technique of focusing the client on the usual course of action that must precede drawing any conclusions about the cause of the cleint's pain.

A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain scales should the nurse use to determine the infant's pain level?

FLACC

A nurse is planning care for 2-month-old infant following a surgical procedure. Which of the following pain rating scales should the nurse plan to use to determine the infant's level of pain?

FLACC scale

A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify?

Fetal position is persistent occiput posterior.

A nurse is preparing an in-service about the various supplements clients might use. Which of the following herbal supplements should the nurse include as potentially increasing the anticoagulant effects of aspirin and other oral anticoagulants?

Feverfew

A nurse is caring for a client who reports difficulty sleeping while in the hospital. Which of the following actions taken by the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene?

Flushes the client's toilet after emptying the urinary catheter's drainage bag

A nurse is caring for a 3-year-old child whose parents report that she has an intense fear of painful procedures, such as injections. Which of the following strategies should the nurse add to the child's plan of care? (Select all that apply.)

Have a parent stay with the child during procedures Perform the procedure as quickly as possible Allow the child to keep a toy from home with her

A nurse is preparing to administer morphine 4 mg IV bolus to a client who reports pain. Available is morphine 10 mg/mL. Which of the following actions should the nurse take?

Have another nurse witness the disposal of the extra medication.

A nurse is teaching a client who had a total knee arthroplasty about self-administering morphine via a patient-controlled analgesia (PCA) infusion device. Which of the following client statements indicates an understanding of the teaching?

I should tell the nurse if i cant control my pain with this device.

A nurse is teaching a client who reports insomnia about promoting rest and sleep. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

I will no longer have a glass of wine before bedtime

A charge nurse is teaching a group of nurses about clients who report using garlic, ginger, and ginkgo biloba. The charge nurse should identify which of the following as an adverse effect of these supplements?

Increased effects of oral anticoagulants

A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery?

It facilitates the client's deep breathing

A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?

Massage the client's back

A nurse is caring for a client who has opioid toxicity and has a respiratory rate of 6/min. Which of the following medications should the nurse plan to administer?

Naloxone

A nurse is planning to administer butorphanol to a client who is in labor. Which of the following medications should the nurse plan to have available to reverse the action of this medication?

Naloxone

A nurse is preparing to administer morphine IV to a client. Which of the following medications should the nurse plan to have available?

Naloxone

A nurse is caring for a client who is dying of metastatic breast cancer. She has a prescription for an opioid pain medication PRN. The nurse is concerned that administering a dose of pain medication might hasten the client's death. Which of the following ethical principles should the nurse use to support the decision not to administer the medication?

Nonmaleficence

A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parental nutrition administration and reports a pain level of 6 on a scale from 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first?

Obtain vitals on both clients

A nurse is administering morphine 2 mg IV every 2 to 4 hr to a client who has an abdominal incision. The nurse should monitor the client for which of the following adverse effects?

Orthostatic hypotension

A nurse is admitting an older adult client who has diabetic neuropathy with painful, burning feet. Which of the following interventions should the nurse anticipate the health care provider to prescribe?

Place a bed cradle on the client's bed

A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point. (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

RLQ

A nurse is preparing a presentation at a community center about complementary and alternative therapies. Which of the following therapies should the nurse describe as placing her hands on or above the client's body to transfer energy to the client?

Reiki

A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take?

Remove the catheter and insert another into a different site

A nurse is assessing a client 15 min after administering morphine sulfate 2 mg via IV push. The nurse should identify which of the following findings as an adverse effect of the medication?

Respiratory rate 8/min

A nurse is caring for a client who has a herniated lumbar disc and reports pain. The nurse should assist the client into which of the following positions to help reduce the pain?

Semi-Fowler's with pillow under her knees

A nurse is teaching a client who has a new prescription for ibuprofen to treat hip pain. Which of the following instructions should the nurse include in the teaching?

Take the medication with food

A hospice nurse is caring for a client who has terminal cancer and takes PO morphine for pain relief. The client reports that he had to increase the dose of morphine this week to obtain pain relief. Which of the following scenarios should the nurse document as the explanation for this situation?

The client developed a tolerance to the medication

A nurse is assessing a client at a follow-up clinic visit for acute low back pain. A goal for this client is to use proper body mechanics at all times. Which of the following findings indicates that the client is meeting this goal?

The client faces the direction of movement when sliding an object across the floor

A nurse is reviewing the medication administration records of four clients who have a prescription for morphine PRN. Which of the following findings should the nurse identify as a contraindication to this medication?

The client has a paralytic ileus

A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pan?

The client's self-report of pain severity

A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level?

a self-report pain rating scale

A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take?

auscultate bowel sounds

A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate?

before the examination, your provider will give you a sedative that will make you sleepy

A nurse is caring for a client who reports having chronic constipation. Which of the following herbal supplements should the nurse recommend?

flaxseed

A nurse is caring for a 6-month-old infant. Which of the following findings indicates to the nurse that the infant may be experiencing pain?

furrowed brow

A nurse is caring for a female client who has rheumatoid arthritis and asks the nurse if it is safe for her to take aspirin. The nurse should recognize which of the following findings in the client's history is a contraindication to this medication?

history gastric ulcers

A nurse is assessing a client who reports acute pain. The nurse should anticipate which of the following findings?

increased heart rate

A nursing is planning care for an adolescent who is postoperative following scoliosis repair with Harrington rod instrumentation. Which of the following interventions should the nurse include in the plan of care?

initiate the use of a PCA pump for pain control

A nurse is teaching a client who takes acetaminophen daily to manage mild knee pain. The nurse should instruct the client to monitor for which of the following adverse reactions to this medication?

jaundice

A nurse is preparing to administer nalbuphine to a postoperative client who is experiencing pain. The nurse should monitor the client for which of the following potential adverse effects of this medication?

miosis

A nurse is assessing a client prior to the administration of morphine. The nurse should recognize that which of the following assessments is the priority?

respiratory rate

A nurse is caring for a client who is postoperative following abdominal surgery and reports incisional pain. The surgeon has prescribed morphine 4 mg IV bolus every 6 hr as needed. Before administering this medication, the nurse should complete which priority assessment?

respiratory rate

A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (Select all that apply.)

restlessness, grimacing, clenching

A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?

self-report of pain

A nurse is caring for a client who reports low back pain and asks the nurse for specific exercise recommendations. Which of the following activities should the nurse suggest?

swimming

A nurse is caring for a client who has acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention?

with hold oral fluids and food