NCLEX PN Review - Hygiene and Pain Questions
the nurse is preparing to provide mouth care to an unconscious client. the nurse collects which items to perform this procedure. select all that apply? Mouthwash Laryngoscope A soft toothbrush Oral suction catheter Bite stick or a padded tongue blade
mouthwash // a soft toothbrush // oral suction catheter // bite stick or a padded tongue blade rationale a soft toothbrush and mouthwash are needed to perform oral care. a bite stick or padded tongue blade is used to open the mouth; the nurse should not used gloved fingers to open the mouth to prevent injury to self. small volumes of fluid are used in cleaning the mouth, and oral suctioning is used to prevent aspiration. a laryngoscope is not needed; this would be used for intubation.
a transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with pain, and the nurse provides information to the client about the TENS unit. which statement by the client indicates the need for further teaching? A) the unit relieves pain B) electrodes are attached to the skin C) the unit will reduce the need for analgesics D) needles are inserted in the subcutaneous tissue to stimulate the nerve
needles are inserted in the subcutaneous tissue to stimulate the nerve rationale the transcutaneous electrical nerve stimulation unit is a portable unit, and the client controls the system for relieving pain and reducing the need for analgesics. it is attached to the skin of the body by electrodes. needles are not used
the nurse has just received report on a newly admitted client who is cognitively impaired and experiencing pain. which data collection techniques should be included in this client's plan? select all that apply observe for grimacing listen for vocalizations observe facial expressions use a numerical pain scale monitor for changes in behavior use Wong-Baker Faces pain rating scale
observe for grimacing // listen for vocalizations // observe facial expressions // monitor for changes in behaviors rationale assessing grimacing, vocalizations, behavioral changes, and facial expressions are all appropriate with a cognitively impaired client. a cognitively impaired client is likely unable to provide the nurse with a number rating of pain and will be unlikely to be able to understand and use the Wong-Baker scale
a client with new onset migraine headaches is being seen in the clinic. the client has a history of hypotension and diabetes mellitus. the nurse predicts that the client will experience undesirable cardiac side effects if the health care provider prescribes which medications? select all that apply verapamil (calan) propranolol (inderal) sumatriptan (imitrex) topiramate (tompamax) divalproex (depakote)
verapamil (calan) // propranolol (inderal) rationale if the client is prescribed verapamil (calan) or propranolol (inderal), there is a risk that the medications will decrease the client's blood pressure. because the client already has a history of hypotension, this is not desirable. sumatriptan, topiramate, and divalproex do not have a significant effect on blood pressure
the nurse on a medical unit is instructing the UAP regarding toileting needs of the assigned clients. which is the order of priority in which the UAP should assist these cients? a client who was admitted 2 days ago with a pelvic fracture an ambulatory client who was admitted for urinary tract infection a client who had left foot amputation 5 days ago a client who has early Alzheimer's dementia
1. a client who was admitted 2 days ago with pelvic fracture 2. a client who had left foot amputation 5 days ago 3. a client who has early Alzheimer's dementia 4. an ambulatory client who was admitted for urinary tract infection rationale the UAP should help first the client who has pelvic fracture because this client has the most limitations with toileting. the client with left foot amputation may be able to transfer independently to a bedside commode. the client with early dementia requires only a reminder to use a bathroom. the last client is independent with toileting because they are ambulatory
the nurse is preparing to bathe a client who has mild Alzheimer's dementia and requires minimal help with hygiene. which is the priority order of nursing interventions? arrange the actions in the order that they should be performed. develop a therapeutic relationship with the client provide a back massage for relaxation document interventions and the clients response allow the client to select the type of bath address privacy by closing the door and pulling the curtains around the bed
1.develop a therapeutic relationship with the client 2.address privacy by closing the door and pulling the curtains around the bed 3. allow the client to select the type of bath 4. provide a back massage for relaxation 5. document interventions and the client's response rationale the nurse's first step in bathing a client with cognitive impairment is to develop a therapeutic relationship. this will help reduce the client's anxiety. allowing the client to select the type of bath involves the client in the planning process and helps provide compliance during bathing. providing privacy will reduce noise and discomfort of exposure that may trigger apprehension in a cognitively impaired client. documentation is the last step in the chain of nursing interventions.
the nurse is providing eye care to an unconscious client. which action does the nurse take with a clean, wet cotton ball to cleanse the eye? A) moving from the lower eyelid up to the top eyelid B) moving from the inner canthus to the outer canthus C) movign from the outer canthus to the inner canthus D) moving from the upper eyelid down to the lower eyelid
B) moving from the inner canthus to the outer canthus rationale the nurse cleanses the eye by wiping from the inner canthus to the outer canthus. this provides for the best asepsis because it moves from a cleaner area to a dirtier one. the other options are incorrect.
the nurse evaluates that the older client has a need for further teaching on how to promote sleep when the client makes which statement? A) i swim three times a week B) i have stopped smoking cigards C) i drink hot chocolate before bedtime D) i read for 40 minutes before bedtime
C) i drink hot chocolate before bedtime rationale many nonpharmacological sleep aids can be used to influence sleep the client should avoid caffeinated beverages and stimulants (e.g. tea, cola, chocolate) and foods that contain tyrosine (e.g cheddar cheese) the client should exercise regularly because exercise promotes sleep by burning off tension that accumulates during the day. a 20- to 30-minute walk, swim, or bicycle ride 3 times a week is helpful. smoking and alcohol should be avoided. the client should avoid large meals, peanuts, beans, fruit and raw vegetables that produce gas, and snacks that are high in fat and difficult to digest
the nurse reviews the care plan for a client who is having difficulty sleeping. which bedtime snack will help the client achieve a restful night's sleep? A) a beef taco B) a cup of tea C) a substantial snack D) a glass of warm milk
D) a glass of warm milk rationale milk contains the essential amino acid tryptophan, which enhances sleep by promoting the production of the neurotransmitter serotonin in the brain. the client should avoid spicy foods and a large intake just before bedtime. the client should also avoid caffeine after noon.
the nurse is assisting in the care of a client receiving codeine sulfate for pain. the nurse should make note of which finding to detect an adverse effect of this medication? A) onset of hypertension B) fluid volume excess C) strength of peripheral pulses D) frequency of bowel movements
D) frequency of bowel movements rationale the client taking codeine sulfate is at risk for constipation. thus, the nurse monitors monitors the frequency of bowel movements. the nurse also would monitor the client for hypotension, decreased respirations, and urinary retention. the nurse would plan measures to counteract these expected effects such as encouraging fluids, coughing and deep breathing, and increasing mobility to the extent tolerated by the client
a client arrives at the clinic complaining of a severe headache. the client states it's a 10/10 headache. i took 600 mg of ibuprofen (motrin) over the past few hours, and it has not decreased the pain. the nurse suspects that the client is experiencing a migraine but wants to validate the suspicion by asking which questions. select all that apply can you describe the pain what other symptoms are you experiencing have you had any recent injuries to your head what did you experience right before the headache began do you or your family have a history of severe headaches
can you describe the pain // what other symptoms are you experiencing // what did you experience right before the headache began // do you or your family have a history of severe headaches rationale describing the pain can help differentiate the different types of headaches. migraines can be accompanied by photophobia and phonophobia among other symptoms. sometimes migraines are preceded by an aura. migraines can sometimes be seen across the generations in families. recent head injuries are more indicative of head trauma not a migraine.
the nurse is performing oral care for a newly admitted client who is undergoing chemotherapy for thyroid cancer. the nurse should take which actions while performing oral care? select all that apply wear sterile gloves provide a soft toothbrush check oral mucous membranes check for missing teeth and cavities provide abrasive toothpaste to remove plaque
provide a soft toothbrush // check oral mucous membranes // check for missing teeth and cavities rationale the nurse should assess oral mucous membranes for sores caused by chemotherapy. a soft toothbrush should be provided to prevent irritation of the mucous membranes. assessment of the client's dentition helps identify any limitations in diet. the nurse should use clean gloves while helping with oral hygiene. abrasive toothpaste may cause irritation of the client's mucous membranes and bleeding.
when reinforcing instructions to an oriented client and the client's family regarding how to use the patient controlled analgesia (PCA) pump with both a basal and demand dose, the nurse should include which instructions? select all that apply report an inability to void notify the nurse if nausea and vomiting occur let the nurse know the pain level the client is experiencing instruct a family member how to push the button every 6 minutes if the client is napping or asleep instruct the client to push the button when the pain level begins to increase
report an inability to void // notify the nurse if nausea and vomiting occur // let the nurse know the pain level the client is experiencing // instruct the client to push the button when the pain level begins to increase rationale PCA pumps have opioids infusing. opioids can have an effect on the parasympathetic nervous system causing nasuea, vomiting, urinary retention, and constipation. the nurse should be kept informed about the pain relief achieved by the client and if there is any breakthrough pain. the client needs to be instructed to push the button before the pain becomes too great. because the client is oriented and there is a basal dose being administered, there is no need for the family to push the button for pain relief. in addition, the client not the family should be controlling the need for medication
the nurse is encouraging an older incontinent client's participation in recreational therapy. what nursing intervention should the nurse consider performing first? A) have the client's nails manicured B) have the client's hair washed and cut C) ask the client to wear supportive shoes D) change the client's soiled disposable brief
D) change the client's soiled disposable brief rationale basic physiological needs are a priority in administering nursing care although options A, B and C address the client's needs, the priority would be to keep the client clean and dry and to avoid embarrassment
the nurse is providing directions to the unlicensed assisted personnel (UAP) regarding clients' hygiene needs. which is the priority order in which the UAP should assist the clients? arrange the actions in the order that they should be performed. a client who is independent with ADLS a client who is on bed rest after multiple traumas a confused client who is incontinent of stool and urine a client who was admitted for dehydration and failure to thrive
1. a confused client who is incontinent of stool and urine 2. a client who is on bed rest after multiple trauma 3. a client who was admitted for dehydration and failure to thrive 4. a client who is independent with ADLS rationale the confused client should be bathed first because bowel/bladder incontinence would lead to skin breakdown. the client who has multiple traumas is at risk to develop skin breakdown and wound infection. the client who was admitted for dehydration and failure to thrive requires assistance with hygiene needs. the client who is independent with ADLs does not require assistance with hygiene.
the client asks the nurse about various herbal therapies available for the treatment of insomnia. the nurse should encourage the client to discuss the use of which product with the health care provider? A) garlic B) valerian C) lavender D) glucosamine
B) valerian rationale valerian has been used to treat insomnia, hyperactivity, and stress. it has also been used to treat nervous disorders such as anxiety and restlessness. garlic is used as an antioxidant and to lower cholesterol levels. lavender is used as an antiseptic and fragrance for a mild sedative effect. glucosamine is an amino acid that assists with the synthesis of cartilage
the nurse is comparing the use of nalbuphine (Nubain) versus meperidine (Demerol) for pain management for a pregnant client. which statement is true with regard to the use of nalbuphine or meperidine? A) Meperidine is effective in creating an amnesic effect B) Meperidine is lessl ikely to cause nausea and vomiting C) Nalbuphine can be used for a client with an opioid dependency D) Nalbuphine is less likely to cause significant respiratory depression
D) Nalbuphine is less likely to cause significant respiratory depression rationale Nalbuphine is an opioid agonist-antagonist analgesic. it provides adequate analgesia without causing significant respiratory depression in the mother or neonate. it is less likely to cause nausea and vomiting when compared with meperidine. it is not suitable for women with an opioid dependence because the antagonist activity could precipitate withdrawal symptoms (abstinence syndrome) in the mother and her newborn). meperidine is an opioid agonist analgesic that can decrease gastric emptying and increase nausea and vomiting. it can cause respiratory depression. it does not have an amnesic effect.
a postoperative client has been receiving morphine sulfate every 3 to 4 hours for pain. the nurse should be sure to implement which measure to reduce the risk of adverse effects from this medication? A) encourage fluids B) monitor the client's temperature C) maintain the client in a supine position D) encourage coughing and deep breathing
D) encourage coughing and deep breathing rationale morphine sulfate suppresses the respiratory and cough reflex. the client should be encouraged to cough and deep breathe in order to prevent atelectasis and subsequent pneumonia. keeping the client in a supine position is harmful because it could lead to atelectasis. monitoring the temperature will detect infection but not prevent it. encouraging fluids will help liquefy secretions for coughing but will not prevent atelectasis unless coughing and deep breathing also are performed
a client is complaining of back discomfort and does not want any pain medication. the nurse has decided to administer a back massage to the client. the nurse should perform the actions in which priority order? dim lights perform hand hygiene collect appropriate equipment help client into a comfortable position check skin areas for redness and integrity verify the client's identity and explain the procedure to the client administer the massage
check skin areas for redness and integrity // collect appropriate equipment // verify the client's identity and explain the procedure to the client // perform hand hygiene // help client into a comfortable position // dim lights // administer massage rationale before beginning any procedure that will increase pressure to the skin, the skin should be assessed for redness (already irritated areas) and breakdown. after accomplishing this and determining it is safe to proceed, the nurse should gather the equipment (towels, lotions, etc) the nurse will then need to verify the client's identity using two forms of identification. this will help eliminate any possible massage on a client for whom it is contraindicated. it is essential to explain to the client the procedure to be used. next the nurse will cleanse his or her hands to prevent transmission of bacteria from the nurse to the client. then assist the client into a comfortable position, either sitting or lying. the massage will be more effective if the client is comfortable at the beginning of the procedure. dimming the lights helps promote relaxation.
