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Ch 49 Terms


What is the basic functional and structural unit of the kidneys? The process of emptying the bladder is known as ________. What is urinary incontinance? What is autonomic bladder?



any involuntary loss of urine voiding by reflex only because the person does not have voluntarily control either due to brain injury or disease or the higher nerve centers have not yet developed such as in infancy. True: Because the first urine of the day is not fresh, but rather an accumulation of a number of hours of kidney output during sleep, this urine may or may not be used as a specimen for certain tests. True: The reason for this is believed to be stagnation of urine in the bladder, which serves as a good medium for bacterial growth

T/F The first urine of the day is usually more concentrated than what is voided throughout the day.

T/F People who habitually urinate infrequently develop more urinary tract infections and kidney disorders than those who urinate at least every 3 to 4 hours. A change in a persons normal voiding pattern may indicate _____.

illness or disease

Intentional or involuntary enuresis urination into bed or clothes that ( is not seen as a medical problem until the child occurs after an age when reaches 6 years of age) continence should be present is termed _______. What types of food or fluid would increase urine production? What in the diet would decrease urine production? Caffeine, alcohol, and foods high in water

high amounts of sodium

What is hematuria? What is polyuria T/F a sterile urine specimen is required for routine urinalysis. If a sterile urine specimen is required which collection method would be used? In a 24 hour urine specimen, is the first urine eliminated counted or thrown out? What are the variables in helping pts maintain normal voiding habits? How many mL should a healthy adult drink per day? What is the main cause of nosocomial infections? Which type of catheter is preferred for long term urinary drainage? What is the Valsalva Maneuver? Why might the Valsalva maneuver be contraindicated in people with cardiovascular problems and other illnesses?

blood in the urine excessive urine output False

clean catch or mid-stream

Thrown out; all urine output for the next 24 hours is collected.

schedule, privacy, position, & hygiene

2,000-2,400 mL


suprapubic catheter

The technique of bearing down to deficate.

Bearing down decreases blood flow to the atria and ventricles, thus temporarily lowering cardiac output. Once bearing down ceases, the pressure is lessened, and a larger than normal amount of blood returns to the heart. This act may dangerously elevate the blood pressure in an already hypertensive individual. Less diapers to change! - breastfed infants can pass from two to ten stools daily, whereas bottlefed infants typically pass one or two stools daily.

Megan, why should you switch to bottle feeding?

What could be suspected when a patient reports that his or her stool has become narrower or ribbon-like? The frequency of bowel sounds may range from ___-___ per minute depending on the rate of peristalsis. How many minutes must you listen for before declaring absent bowel sounds? A combination of which three things has been shown to be as effective as medications in controlling constipation? What is the most common cause of chronic constipation?

There may be an obstruction of the normal passage of stool through the colon such as a tumor.


5 min.

high-fiber foods, 8 to 10 glasses of water daily, and exercise

habitual laxative use

Ch 35

1. A client is nauseated, has been vomiting for several hours, and needs to receive an antiemetic (anti-nausea) medication. The nurse recognizes that which of the following is accurate?

A parenteral route is the route of choice. contraindicated if there is rectal bleeding or if the client had rectal surgery. Stool in the rectum can impair absorption.

2. The client receiving an intravenous infusion of morphine sulfate begins to experience respiratory depression and decreased urine output. This effect is described as:


3. The client is to receive a medication via the buccal route. The nurse plans to implement which of the following actions?

Place the medication inside the cheek.

4. The physician orders a grain and a half of Seconal to help a client sleep. The label on the medication bottle reads Seconal 100 mg. How many capsules should the nurse give the client?

1 Because 1 grain = 60 mg, the nurse may multiply 1 by 60 to equal 90 mg. The nurse may then use the following formula for calculating a drug dosage: 90 mg 100 mg x 1 capsule = 0.9 capsules Because 0.9 of a capsule cannot be administered, it is rounded to 1 capsule. The nurse will administer 1 capsule. 2/5 mL The nurse should use the following formula to calculate a drug dosage: 6 mg 15 mg x 1 mL = 2/5 mL Body surface area

5. The physician has ordered 6 mg of morphine sulfate every 3 to 4 hours prn for a client's postoperative pain. The unit dose in the medication dispenser has 15 mg in 1 mL. How much solution should the nurse give? 6. To determine proper drug dosages for children, calculations are most precisely made on the basis of the child's: 7. The nurse is documenting administration of a medication that is given at 10:00 AM, 2:00 PM, and 6:00 PM. The medication that the nurse is documenting is: 8. The nurse is working on the pediatric unit. In preparing to give medications to a preschool-age child, an appropriate interaction by the nurse is:

Diazepam 5 mg PO tid

"Would you like the medication with water or juice?"

9. In preparing two different medications from two vials, the nurse must:

Discard the medication from vial number 2 if medication from vial number 1 is pushed into it

10. The nurse is teaching the client how to prepare 10 units of regular insulin and 5 units of NPH insulin for injection. The nurse instructs the client to: 11. A client has a prescription for a medication that is administered via an inhaler. To determine if the client requires a spacer for the inhaler, the nurse will determine the: 12. The student nurse reads the order to give a 1-year-old client an intramuscular injection. The appropriate and preferred muscle to select for a child is the: 13. The nurse administers the intramuscular medication of iron by the Ztrack method. The medication was administered by this method to: 14. The client is ordered to have eye drops administered daily to both eyes. Eye drops should be instilled on the: 15. Following the administration of ear drops to the left ear, the client should be positioned: 16. The order is for eye medication, ii gtt OD. The nurse administers:

Inject air into both vials and withdraw the regular insulin first

Coordination of the client


Prevent the drug from irritating sensitive tissue

Lower conjunctival sac

Right lateral

2 drops to the right eye ii = 2; OD = right eye. OS = left eye. OU = both eyes.

17. The most effective way in the acute care environment to determine the client's identity before administering medications is to: 18. An order is written for Demerol 500 mg IM q3-4h prn for pain. The nurse recognizes that this is significantly more than the usual therapeutic dose. The nurse should: 19. An order is written for 80 mg of a medication in elixir form. The medication is available in 80 mg/tsp strength. The nurse prepares to administer: 20. The client is to receive a Mantoux test for tuberculosis. This test is administered via an intradermal injection. The nurse recognizes that the angle of injection that is used for an intradermal injection is: 21. The nurse prepares to administer an intradermal injection for the administration of medication for: 22. The nurse is evaluating the integrity of the ventrogluteal injection site. The nurse finds the site by locating the: 23. The client is to receive heparin by injection. The nurse prepares to inject this medication in the client's:

Check the client's name band

Call the prescriber to clarify the order

5 mL

15 degrees

Allergy sensitivity

Greater trochanter, anterior iliac spine, and iliac crest


24. A medication is prescribed for the client and is to be administered by IV bolus injection. A priority for the nurse before the administration of medication via this route is to: 25. A client on the medical unit receives regular insulin at 7:00 AM. The nurse is alert to a possible hypoglycemic reaction by:

Confirm placement of the IV line

10:00 AM Regular insulin reaches its peak in 2 to 4 hours after administration. Regular insulin has an onset in 30 minutes. Intermediate-acting insulin (i.e., NPH insulin) would peak in 6 to 12 hours, not regular insulin. Checking for a gag reflex

26. A priority for the nurse in the administration of oral medications and prevention of aspiration is: 27. The nurse is to administer several medications to the client via the N/G tube. The nurse's first action is to: 28. The nurse is administering an injection at the ventrogluteal site. On aspiration, the nurse notices that there is blood in the syringe. The nurse should: 29. A 3-year-old child is to receive an iron preparation orally. The nurse should: 30. The client has an order for 30 units of U-500 insulin. The nurse is using a U-100 syringe and will draw up and administer: 31. The nurse is preparing to administer 8 mg of a 10 mg dose of an intravenous narcotic. Which of the following statements made by the nurse best reflects an understanding of the appropriate

Check for placement of the nasogastric tube

Discontinue the injection and prepare the medication again

Use a straw

6 units

"I need to get another RN to witness the waste and sign the narcotic sheet."

manner to handle this situation? 32. The nurse is caring for a client who is experiencing severe pain and is insistent about "getting some relief quickly." Which of the following prescriptions is most likely to produce the quickest pain relief? 33. A 78-year-old client with congestive heart failure (CHF) is reporting vascular pain in his lower legs and requests his oral narcotic analgesic. The nurse recognizes that the client's pain relief will be negatively affected primarily because of 34. The nurse is aware that which of the following clients is at greatest risk for developing medication toxicity? 35. A 20 year old diagnosed with Crohn's disease is experiencing severe pain and is requesting the prescribed morphine as often as it can be administered. The nurse is particularly concerned about opioid toxicity because of: 36. The nurse recognizes which of the following clients as being at greatest risk for anaphylactic shock? 37. During the admission interview a client shares with the nurse that she is allergic to latex. The nurse's immediate response is to: Morphine sulfate intravenously

The systemic effects of CHF

The 73-year-old diagnosed with hepatitis B

The client's compromised bowel absorption

A 69-year-old client receiving an antibiotic for a respiratory tract infection

Place an identification bracelet on the client that identifies the latex allergy

38. A client is observed swallowing a chewable form of aspirin. Which of the following statements made by the nurse shows the best understanding of the educational reinforcement needed by this client? 39. To minimize the risk for injury to the oral mucosa, a client ordered a buccally administered medication is instructed to: 40. To best prevent a systemic effect from a topically applied medication patch, the nurse must: 41. The nurse assigns ancillary personnel the task of giving a client a pre-procedure enema. Which of the following statements made by the personnel requires immediate follow-up by the nurse? 42. Research has shown that the primary reason nurses make medication errors is related to: 43. The nurse has taken a verbal order for a narcotic medication to be given to a client experiencing severe pain related to metastatic cancer of the bone. The nurse's initial action regarding the order is to: 44. During the admission interview the client reports to the nurse that she is "a little allergic to penicillin." Which of the following questions asked by the nurse is most likely to provide the most relevant information regarding the client's possible

"I realize that you usually swallow aspirin, but this form only works if it's chewed."

Alternate cheeks with each subsequent dose

Avoid applying the medication to broken skin

"The soapy water just came right back out."

Events that distract the nurse during the administration process

Write and then sign the complete order in the appropriate location in the client's chart

"Can you describe what happens when you take penicillin?"

allergy to penicillin? 45. Policies for the proper storage and distribution of narcotics within a health care organization are written by: 46. The nurse is administering morphine sulfate to a client for pain. The order has been written so that the nurse can chose from several routes of administration. The nurse knows that the morphine sulfate be most rapidly absorbed by which of the following routes? 47. On beginning the administration of 500 mg of aztreonam IV to a client with a urinary tract infection, the client complains of difficulty breathing. The nurse quickly identifies this as a symptom of a(n): Health care organization


Anaphylactic reaction

48. In the event of a medication error, the nurse's first responsibility is to: 49. The nurse prepares to administer a table to a client who has difficulty swallowing pills. The nurse decides to crush the tablet and mix it with food. The nurse should mix the crushed medication: 50. The nurse prepares to administer a prn pain medication by IM injection. The client refuses the injection stating that "I don't like shots." The best reaction by the nurse is to:

Ensure the client's safety

In a very small amount of food

Contact the physician for pain medication to be given by a different route

51. When teaching a pediatric client's parents about administering his medication at home, the nurse states that the most accurate device for measuring the liquid medication is: 52. The nurse is preparing to administer a nasal instillation of medication to a client. The best position for accessing the posterior pharynx is to place the client in a supine position and tilt the client's head: 53. The nurse has an order for 325 mg acetaminophen p.r. q4h prn for pain for a 7-year-old client who has had surgery. In preparing the client for insertion of the suppository, the client states that she feels the need to have a bowel movement. The nurse's best response is to: 1. The nurse plays a major role in which of the following aspects of medication therapy? (Select all that apply.)

Oral plastic disposable syringe


Allow the client to defecate first to clear the rectum of stool

3. Preparation of the client's prescribed dose of medication 4. Monitoring the pharmacological effects of the prescribed medication 5. Delivering the medication in accordance with the prescriber's directions 6. Instructing the client regarding the pharmacological effects of the medication The nurse plays an essential role in medication preparation and administration, medication teaching, and evaluating clients' responses to medications. The remaining options are not in the nursing scope of the RN. 1. "This medication is designed to lower your blood pressure."

2. The home health nurse is preparing to educate a client on his or her newly

prescribed medications. Which of the following nursing statements are appropriate to be included in this discussion? (Select all that apply.)

3. "The medication can make you dizzy especially if you stand up quickly." 4. "What do you think will be the most difficult thing about taking this medication?" 5. "You will need to take this medication once a day; with breakfast seems to work best for most people." 6. "It is important that you don't miss taking the medication, If you do, take it when you remember but never take two at a time." Teaching clients about their medications and their side effects, ensuring adherence with the medication regimen, and evaluating the client's ability to self-administer medications are nursing responsibilities. The remaining option does not relate to the actually medication regimen. 1. Years of imprisonment in a federal prison 3. Inclusion on the State Board of Nursing Suspended license list 4. Forfeiture of the professional license needed to practice nursing 5. Monetary fines that can be in the hundreds of thousands of dollars 6. Termination of employment from the institution where the abuse occurred Violations of the Controlled Substances Act are punishable by fines, imprisonment, and loss of nurse licensure. 1. A 16 year old with asthma 2. A 34 year old with hepatitis B 4. A 20 year old with Crohn's disease 5. A 54 year old in end-stage renal failure After medications are metabolized, they exit the body through the kidneys, liver, bowel, lungs, and exocrine glands.

3. A nurse is accused of illegally abusing narcotic medications originally prescribed to clients. If found guilty this nurse is subject to: (Select all that apply.)

4. Which of the following clients is likely to experience altered medication excretion with resulting possible toxicity? (Select all that apply.)

5. The pharmacist provides collaboration to the acute care nursing staff in the form of: (Select all that apply.) 1. Accurate dispersal of prescribed medications 2. Information regarding medication side effects 3. Appropriate labeling of prescribed medications 4. Clarification regarding proper medication dosage 5. Education of clients regarding the therapeutic value of drugs 6. Answering questions related to potential drug incompatibilities

1. Accurate dispersal of prescribed medications 2. Information regarding medication side effects 3. Appropriate labeling of prescribed medications 4. Clarification regarding proper medication dosage 6. Answering questions related to potential drug incompatibilities Most medication companies deliver medications in a form ready for use. Dispensing the correct medication in the proper dosage and amount and with an accurate label is the pharmacist's main task. The pharmacist also provides information about medication side effects, toxicity, interactions, and incompatibilities. Client education is not a collaborative action provided by the pharmacist; client education is a nursing responsibility. 1. Immediate assessment of the client 2. Notification of the health care provider 3. Report the error to the appropriate institutional administrator 6. Monitoring of the client as indicated by the potential effects of the medication When an error occurs, the client's safety and well-being become the top priority. The nurse assesses and monitors the client's condition and notifies the physician or prescriber of the incident as soon as possible. Once the client is stable, the nurse reports the incident to the appropriate person in the institution. The nurse is responsible for preparing a written occurrence

6. The nursing role regarding a medication error includes: (Select all that apply.) 1. Immediate assessment of the client 2. Notification of the health care provider 3. Report the error to the appropriate institutional administrator 4. Notify the client's family or medical power of attorney of the error 5. Attach a written incident report to the client's chart within 24 hours 6. Monitoring of the client as indicated by the potential effects of the medication

or incident report that usually needs to be filed within 24 hours of the error. The occurrence report is not a permanent part of the medical record and is not referred to anywhere in the record. Notification of the client's family is not required unless the client's condition warrants it

Ch 38
1. The nurse has investigated safety hazards and recognizes that which one of the following statements is accurate regarding safety needs? 1. Bacterial contamination of foods is uncontrollable. 2. Fire is the greatest cause of unintentional death. 3. Carbon dioxide levels should be monitored in home settings. 4. Temperature extremes seldom affect the safety of clients in acute care facilities. 2. An ambulatory client is admitted to the extended care facility with a diagnosis of Alzheimer's disease. In using a falls assessment tool, the nurse knows that the greatest indicator of risk is: 3. An inservice program is being offered in the hospital on bioterrorism and the response of the health care agency. During the program, the mitigation phase is described. The nurse is informed that this phase includes: 4. An inservice program is being offered in the hospital on bioterrorism and the response of the health care agency. An important aspect of the program is the recognition of the signs and symptoms of bacterial and viral infections. A practice drill is held and the nurse recognizes that the clients admitted with possible anthrax will demonstrate:

Carbon dioxide levels should be monitored in home settings.

History of falls

Determination of hazard vulnerability and the impact of the emergency situation

Flulike symptoms, gastrointestinal distress, and papular lesions

5. A 1-year-old child is scheduled to receive an IV line. The most appropriate type of restraint to use for this client to prevent removal of the IV line would be a(n): 6. A 79-year-old resident in a long-term care facility is known to "wander at night" and has fallen in the past. Which of the following is the most appropriate nursing intervention? 7. The workmen cause an electrical fire when installing a new piece of equipment in the intensive care unit. A client is on a ventilator in the next room. The first action the nurse should take is to: 8. In a nursing home an elderly client drops his burning cigarette in a trash can and starts a fire. The most appropriate type of fire extinguisher for the nurse to use is the: 9. A visiting nurse completes an assessment of the ambulatory client in the home and determines the nursing diagnosis of risk for injury related to decreased vision. Based on this assessment, the client will benefit the most from: 10. Which one of the following statements by the parent of a child indicates that further teaching by the nurse is required?

Mummy restraint

The client should be checked frequently during the night.

Use an Ambu-bag and remove the client from the area

Type A

Becoming oriented to the position of the furniture and stairways

"Now that my child is 2 years old, I can let her sit in the front seat of the car with me." Restraints are to be periodically removed to have the client reevaluated Close all the doors of client rooms

11. The nurse assesses that the client may need a restraint and recognizes that:

12. On entering the client's room, the nurse sees a fire burning in the trash can next to the bed. The nurse removes the client and calls in the fire. The next action of the nurse is to: 13. A mother of a young child enters the kitchen and finds

Check the child's airway and

the child on the floor. There is a bottle of cleanser next to the child and particles of the substance around the child's mouth. The parent's first action should be to: 14. Which of the following nursing assessment data are most reflective of hypothermia? 15. Which of the following clients who is experiencing the heat of mid-August is at greatest risk for heatstroke or heat exhaustion? 16. The nurse should recognize which of the following clients as being at greatest risk for an unintentional death? 17. Which of the following nursing interventions has the greatest likelihood of minimizing the risk of injury for a client who frequently gets out of bed at night to go into the bathroom? 18. When discussing the prevention of fire-related injuries and deaths, the nurse should place the greatest emphasis on the: 19. The nurse recognizes that the leading cause of death for the otherwise healthy 1 year old is: 20. The nurse is preparing a safety-related program for a group of parents of 5 to 14 year olds. Which of the following topics is most likely to positively impact the leading cause of injury for this age-group? 21. The nurse recognizes which of the following clients is at greatest risk for an accidental death?


Rectal temperature of 35 C (95 F) A 65-year-old diagnosed with COPD

A 72-year-old identified as at high risk for falls Illuminating the pathway to the bathroom

Dangers of careless smoking habits

Accidental injury

"Bicycle riding with safety in mind"

A 50-year-old who recently lost his job because of a workrelated injury The physical collapse that occurs at the onset of the seizure

22. A client who is experiencing a generalized clonic-tonic seizure is at greatest risk for injury caused by:

23. Which of the following clients is at greatest risk for injury related to medical diagnoses and conditions? 24. The nurse is conducting an admission interview and assessment on a cognitively impaired, uncooperative client for the risk for injury. Which of the following options will most likely provide the information to confirm the diagnosis? 25. A nurse working in an acute care facility's emergency department should recognize which of the following client reports as being most suspicious of a terrorist attack?

A history of heart failure and urinary urgency Interview the client's family, friends, and/or caregivers regarding pre-hospitalization risk factors.

15 cases of nausea and vomiting reported over a 2day period when 4 cases would be within normal for the facility Where do you see a need for safety improvements in your home?"

26. The nurse is discussing safety issues with the mother of three children. Which of the following statements has the greatest possibility for decreasing the potential for injury among the children? 27. The nurse recognizes that the greatest benefit of engaging the mother of two small children into a discussion about child-proofing her home is that: 28. The nurse and a mother of two small children are discussing child safety issues. Which of the following nursing interventions has the greatest potential for using collaboration to help ensure the children's safety? 29. When preparing a safety workshop for early teens (13 to 15 years old), the nurse recognizes that which of the following active strategy topics has the greatest potential for decreasing injuries in this population by affecting lifestyle changes? 30. The nurse is discussing measures to minimize the risk of injury from an automobile accident with an 83-year-old adult client who lives alone and claims to drive only to

She is likely to monitor the house for safety issues in the future Helping the mother create a list of emergency telephone numbers to be posted next to the home's telephone Wearing a seat belt when riding in an automobile

Plan driving for short trips and only during the daylight hours.

church, the doctor's office, and for groceries. Which of the following suggestions has the greatest potential for affecting this client's safety? 31. Which of the following assessment findings is most critical in a client who is currently being restrained with mechanical wrist restraints? 32. The nurse is discussing a newly ordered diuretic with an older adult client who is home-bound. Which of the following suggestions has the greatest potential for minimizing the client's risk for injury related to urinary urgency or incontinence? 33. A nurse caring for an elderly client who has had surgery and is in the hospital knows that the client is at high risk for developing a nosocomial infection. One of the most important things that the nurse can do to prevent this client from obtaining a nosocomial infection is to: 34. The nurse caring for an elderly client in the hospital notes on assessment that the client has a scald burn on her foot. On questioning the client, the nurse learns that the client scalded her foot when adding hot water from the tap to her bath while she was in the tub. The nurse should do which of the following? 35. A nurse in the emergency department (ED) of a community hospital notes that an unusually high number of clients have presented in the ED with flulike symptoms, abdominal pain, nausea, vomiting, bloody diarrhea, hematemesis and itching of the hands, forearms, and head. The nurse is concerned with bioterrorism, reports this to the supervisor, and suspects an outbreak of: 36. When discussing the new mother's pending discharge from the hospital, the nurse determines that additional client teaching needs to take place because of which of the Hands are cool to the touch

Encourage the client to take the medication early in the morning.

Request prophylactic antibiotics for the client

Suggest that the temperature of the hot water heater be lowered.


I can't wait to put my baby in her new crib with the ensemble that my mom made-

following comments?

sheets, blankets, and bumper to match. Provide a trained sitter to continuously supervise the client.

37. A confused client on a ventilator was restrained to prevent him from pulling out his endotracheal tube. Which of the following could be a possible alternative measure that the nurse could use to avoid the use of the restraints? 38. A confused client needs to have restraints to prevent him from pulling out his Foley catheter. Which of the following can the nurse delegate to the nursing assistive personnel? 39. A nurse finds that an electrical cord has shorted out in a client's room, causing a fire. The nurse should do which of the following actions first? 40. Which of the following statements indicates that the client is at risk for an electrical shock at home?

Applying restraints

Remove the client from the room.

My bread got stuck in my toaster this morning, and I unplugged it before trying to remove it." Position the client safely

41. The nurse is caring for a client with a history of epileptic seizures. The nursing assistive personnel notifies the nurse that the client is having a seizure. The first thing that the nurse should do when arriving in the room is to: 42. A client with a history of epilepsy arrives in the emergency department experiencing status epilepticus. The nurse should never do which of the following?

Open client's mouth by placing fingers on jaw and inserting thumb on bottom teeth to place oral airway between seizures.

CH 45
Which one of the following nursing interventions for a client in pain is based on the gate-control theory?

1. Giving the client a back massage

A priority nursing intervention when caring for a client who is receiving an epidural infusion for pain relief is to: The nurse should describe pain that is causing the client a "burning sensation in the epigastric region" as: Which of the following is most appropriate when the nurse assesses the intensity of the client's pain? The nurse on a postoperative care unit is assessing the quality of the client's pain. In order to obtain this specific information about the pain experience from the client, the nurse should ask: When a client's husband questions how a patientcontrolled analgesia (PCA) pump works, the nurse explains that the client:

3. Monitor vital signs every 15 minutes 3. Deep or visceral

3. Offer the client a pain scale to objectify the information 1. "What does your discomfort feel like?"

1. Has control over the frequency of the intravenous (IV) analgesia

An older client with mild musculoskeletal pain is being seen by the primary care provider. The nurse anticipates that treatment of this client's level of discomfort will include: Before inserting a Foley catheter, the nurse explains that the client may feel some discomfort. This is an example of: The nurse knows that a PCA pump would be most appropriate for the client who: A client with chronic back pain has an order for a transcutaneous electrical nerve stimulation (TENS) unit for pain control. The nurse should instruct the client to: The nurse caring for a terminally ill client with liver cancer understands which of the following goals would be most appropriate?

3. Acetaminophen

3. Anticipatory response

2. Is recovering after a total hip replacement 2. Use the unit when pain is perceived

3. Adapt the analgesics as the nursing assessment reveals the need for specific medications.

A client is having severe, continuous discomfort from kidney stones. Based on the client's experience, the nurse anticipates which of the following findings in the client's assessment? Nurses working with clients in pain need to recognize and avoid common misconceptions and myths about pain. In regard to the pain experience, which of the following is correct? A nonpharmacological approach that the nurse may implement for clients experiencing pain that focuses on promoting pleasurable and meaningful stimuli is: Which of the following is the most appropriate nursing intervention for a client who is receiving epidural analgesia?

4. Nausea and vomiting

1. The client is the best authority on the pain experience

2. Distraction

3. Secure the catheter to the outside skin

The client is experiencing breakthrough pain while receiving opioids. An order is written for the client to receive a transmucosal fentanyl "unit." In teaching about this medication, the nurse should instruct the client to: When caring for a client who is experiencing continuous severe pain, the nurse should expect that the pain management plan would include: Which of the following symptoms would the nurse expect with a client who is experiencing acute pain? Which of the following statements made by a nurse shows the greatest understanding of the personal nature of the pain experience?

2. Do not chew the unit after administration

3. Administering opioids with nonopioid analgesics for severe pain experiences 3. Diaphoresis

4. " I can only accept what the client reports concerning the pain being felt and attempt to intervene successfully in its management." 2. "My postsurgical clients get

Which of the following statements made by a nurse

requires follow-up with additional instruction regarding the personal nature of pain?

the prescribed pain medications on schedule with no diversion from the schedule." 3. "I'm exhausted physically and emotionally trying to live with this pain." 4. " Trying to cope with pain is using up the energy so he can get some rest."

Which of the following statements made by a client reporting severe pain expresses the most insight into how pain impacts a client's energy reserves? Which of the following statements made by a nurse caring for a client reporting severe pain expresses the most insight into how pain impacts a client's energy reserves? Which of the following statements made by the nurse regarding the client's self-assessment of pain requires immediate follow-up regarding the personal nature of pain?

4. "She says she's in pain, but she doesn't act like she is in pain."

The nurse recognizes that the most likely reason a runner who has injured his ankle during a race is not aware of it until after he crosses the finish line is that: Which of the following statements by the nurse reflects a need for immediate follow-up regarding the physical effects of chronic pain on body function?

2. His endorphin levels were high as a result of the physical stressors of the race 1. "His pulse and blood pressure are within his normal baseline limits, so i'm sure the pain medication is working" 3."Taking the medication as prescribed will help you to be more active; your family will be happy you can do things with them again." 3. An understanding that it is easier to prevent the pain than to stop the pain

A client with a history of chronic back pain is questioning the need to "keep asking for pain medication," fearing that he will be viewed as being weak by his family. The most therapeutic nursing response to this client would be:

A client who is scheduled for the second in a series of painful dressing changes asks for "my pain medication now so it's working when the dressing is changed" is most likely expressing:

The nurse inquires of a postoperative client as to the need for pain medication. The client denies the need then but 30 minutes later reports, "I am really in a lot of pain. Can you bring me my pain pill now?" The nurse recognizes that the most immediate need for client education is related to explaining that: The nurse is caring for a cognitively impaired client who has experienced a painful procedure. The nurse is most effective in determining the client's pain medication needs when using which of the following assessment methods? The nurse is attempting to ambulate a postoperative client who continues to rate his pain as a 7 on a scale of 0 to 10, with 10 being the most severe. The client is reluctant to walk and consents to move only to the chair, reporting that "it hurts too much to walk." The nurse's primary concern regarding the client's recovery related to his pain experience is that: The nurse is attempting to ambulate an older adult client who recently experienced a fall at the assisted living facility where he resides. The client is reluctant to walk and consents to move only to the chair, reporting that "it hurts too much to walk." Which of the following nursing interventions is most therapeutic regarding this client? A client with chronic pain states, "I just want to be painfree. Do something to make that happen." The most therapeutic response is: The greatest barrier to a 3-year-old client's ability to selfassess her pain is: The nurse is discussing the effects of pain with an older adult client diagnosed with osteoarthritis. The most therapeutic response to the client's comment of, "I wonder whether it would hurt if I took a nap in the afternoon?"

4. His pain will be more effectively managed if he reports a need for pain medication while the pain is still tolerable

4. observing the client's body movements and facial expressions for typical pain behavior 4. He is not ready to participate in the activities needed to recover quickly

4. Assess the client for other factors that may be affecting his ability and motivation to ambulate

1. "Together we will all work at making your pain tolerable."

1.A limited vocabulary

4. " I think a nap is a good idea because we seem to feel pain more when we are tired."

would be: Which of the following statements is the most appropriate response to a client's statement, "I thought you could tell I was in pain"? 4. " I will make a point of asking you to rate your pain at least every 2 hours, so this miscommunication won't happen again." 1."What would be a satisfactory level of pain control for us to achieve?"

A 44-year-old client shares with the admitting nurse that the client is having epigastric pain that the client identifies as a 7 on a 0 to 10 scale. In order to plan for the pain management of this client, which is the most appropriate response from the nurse? The home care nurse notes that a 67-year-old female diabetic client's blood glucose level has been elevated since she strained her back the previous week. The client states that she cannot understand why her blood glucose level is elevated. The nurse suspects the most likely cause for the elevated blood sugar is: A client with chronic pain presents in the emergency department of the local hospital stating "I just can't take this anymore." On questioning the client, the nurse discovers that the client have experienced chronic pain since being involved in an accident 2 years previously. The client states that he has been labeled a "drug seeker" because he is looking for relief for the pain and feels hopeless, angry, and powerless to do anything about the situation. The nurse understands that this client is at risk for: A client who had knee replacement surgery the previous day refuses to take any pain medication, even though he rates his pain as an 8 on a 0 to 10 scale. Upon questioning the client the nurse learns that the reason for refusing pain medication is because he is concerned about injuring the knee and not feeling it. The best information that the

2.Parasympathetic stimulation from the body's normal response to pain


1.The pain medication will help speed his recovery time

nurse can provide this client is to explain that: A 38-year-old client presents to the pain clinic with complaints of phantom pain. The client was involved in a farming accident 3 years previously that resulted in a below-the-elbow amputation of his right arm. The nurse knows that phantom pain is categorized as: The daughter of an 88-year-old female client tells the nurse that her mother has recently quit going on walks in the neighborhood because of pain in her legs. Which of the following is the best response from the nurse? The nursery nurse is explaining postcircumcision care to a new mother. Which of the following statements by the new mother indicates that additional teaching needs to occur? Taking into consideration the hospice client's chronic pain from bone cancer, the most appropriate person to collaborate with regarding management of pain is: in creating the plan of care for a newly diagnosed breast cancer client, the nurse is concerned about pain control. The client has expressed an interest in relaxation therapy as a complementary pain therapy. The nurse knows that the best time to teach the client is: A client who ruptured his spleen in a motor vehicle accident rates his postoperative pain as a level 8 on a 0 to 10 pain scale. After administering pain medication, the nurse discusses the use of complementary therapies with the client to explore ways to reduce the pain. The client would like to try a massage. The nurse delegates this task to the assistive personnel (AP). Which of the following instructions is most important for the nurse to share with the AP? 4.Deafferentation pain

1. " I would like to speak with your mother to get information."

1. "Babies don't experience pain, so i don't need to worry about hurting him when i touch the penis." 4. An oncology nurse

4. When the client is comfortable

3. "do not massage the client's legs."

CH 48

When repositioning an immobile client, the nurse notices redness over a bony prominence. When the area is assessed, the red spot blanches with fingertip touch, indication?

Reactive hyperemia, a reaction that causes the blood vessels to dilate in the injured area Stage 1

This type of pressure ulcer has an observable pressure related alteration of intact skin whose indicators, compared with an adjacent or opposite area on the body, may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or beefy feel), and/or sensation (pain, itching). When obtaining a wound culture to determine the presence of a wound infection, the specimen should be taken from the: Postoperatively the client with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open and pieces of small bowel are noted at the bottom of the now opened wound. The correct intervention would be to: Serous drainage from a wound is defined as: For a client who has a muscle sprain, localized hemorhage, or hematoma, what wound care product helps prevent edema formation, control bleeding, and anesthetize the body part? Interventions to manage a client who is experiencing fecal and urinary incontinence include:

Wound after it has first been cleansed with normal saline

Cover the areas with sterile saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration Clear, watery plasma Ice bag

Utilization of an incontinence cleanser, followed by application of a moisture barrier ointment Addressing that forms a gel that interacts with the wound surface

The best description of a hydrocolloid dressing is:

A binder placed around a surgical client with a new abdominal wound is indicated for: Application of a warm compress is indicated:

Reduction of stress on the abdominal incision To improve blood flow to an injured part

Ch 43

1. When evaluating a patient's pain, the nurse knows that an example of acute pain would be: 2. Which statement indicates that the nurse understands the pain experience in the elderly?

kidney stones.

"Pain indicates pathology or injury and is not a normal process of aging." The Wong-Baker Scale

3. A 4-year-old boy is brought to the emergency department by his mother. She says he points to his stomach and says, "It hurts so bad." Which pain assessment tool would be the best choice when assessing this child's pain? 4. A patient states that the pain medication is "not working" and rates his postoperative pain at a 10 on a 1 to 10 scale. Which of the following assessment findings indicates an acute pain response to poorly controlled pain? 5. A 60-year-old woman has developed reflexive sympathetic dystrophy after arthroscopic repair of her shoulder. A key feature of this condition is that:

Increased blood pressure and pulse

the slightest touch, such as a sleeve brushing against her arm, causes severe, intense pain.

6. The nurse is assessing a patient's pain. The nurse knows that which of the following is

The subjective report

considered the most reliable indicator of pain? 7. A patient has had arthritic pain in her hips for several years since a hip fracture. She is able to move around in her room and has not offered any complaints so far this morning. However, when asked, she states that her pain is "bad this morning" and rates it at an 8 on a 1 to 10 scale. What does the nurse suspect? 8. Which type of pain is due to an abnormal processing of the pain impulse through the peripheral or central nervous system? 9. When assessing the quality of a patient's pain, the nurse should ask which question? She has experienced chronic pain for years and has adapted to it.

Neuropathic pain

"What does your pain feel like?"

10. When assessing a patient's pain, the nurse knows that an example of visceral pain would be: 11. Nociception is the term used to describe how noxious stimuli are typically perceived as pain. During which phase of nociception does the conscious awareness of a painful sensation occur? 2. When assessing the intensity of a patient's pain, which question by the nurse is appropriate? 13. A patient is complaining of severe knee pain after twisting it during a basketball game and is requesting pain medication. Which action by the nurse is appropriate? 14. The nurse knows that which statement is



"How much pain do you have now?"

Administer pain medication and then proceed with the assessment. A procedure that

true regarding the pain experienced by infants?

induces pain in adults will also induce pain in the infant.