pain and comfort
A nurse reviews the MAR for a client with severe pain: Morphine 2 mg IV q4h PRN pain > 6/10. The client rates pain 8/10 two hours after last dose. What should the nurse do?
A. Administer 2 mg IV morphine now.
B. Contact the provider to change frequency.
C. Wait 2 more hours.
D. Document that pain persists.
✅ Answer: B
Rationale: Dose frequency can’t be adjusted by nurse judgment; requires provider order revision.
A client with COPD reports “I can’t sleep lying flat.” The nurse should:
A. Encourage side-lying with 1 pillow.
B. Elevate HOB and apply nasal cannula.
C. Offer sedative to induce sleep.
D. Cluster care at bedtime.
✅ Answer: B
Rationale: Orthopnea → elevation improves oxygenation. Identify physiologic cause of rest disturbance.
A nurse notes new redness over sacrum in a bedbound patient. Which immediate action prevents progression?
A. Apply barrier cream.
B. Reposition and reassess in 1 hour.
C. Massage the area gently.
D. Apply hydrocolloid dressing.
✅ Answer: B
Rationale: Stage I prevention = pressure relief and frequent reassessment, not occlusive dressing.
A nurse documents “Patient appears better.” What is the correct revision?
A. “Patient states, ‘I feel stronger today.’”
B. “Patient improved.”
C. “Patient less anxious.”
D. “Patient more stable.”
✅ Answer: A
Rationale: Use patient quotes or objective data. Objective over interpretive charting ensures accuracy.
A client becomes restless, HR 120, RR 28, O₂ sat 85%, absent right breath sounds.
Which action takes priority?
A. Notify the provider.
B. Elevate HOB and apply 100% O₂.
C. Obtain ABG sample.
D. Reposition onto right side.
✅ Answer: B
Rationale: Restlessness = hypoxia; apply oxygen and optimize ventilation first.
A postoperative patient reports pain of 8/10 two hours after IV morphine. The nurse notes the patient is pale and diaphoretic, with HR 112 and BP 90/58. What is the priority action?
A. Administer another opioid dose.
B. Assess the surgical site for bleeding.
C. Notify the provider for hypotension.
D. Reposition the client and reassess pain.
✅ Answer: B
Rationale: Physiologic cues (tachycardia, hypotension, diaphoresis) suggest acute blood loss, not uncontrolled pain. Assess for hemorrhage before giving additional opioids.
A hospitalized client awakens multiple times due to vital sign checks and alarms. Which action best aligns with QSEN Patient-Centered Care?
A. Explain it’s hospital routine.
B. Collaborate to adjust nighttime schedule.
C. Administer PRN sedative.
D. Provide white noise.
✅ Answer: B
Rationale: Adjusting care routines respects rest needs and safety. Apply teamwork + advocacy
A diabetic client’s foot ulcer has slough and foul odor. Which action requires clarification?
A. Obtain culture before antibiotics.
B. Apply hydrogel and cover.
C. Use Dakin’s (bleach) solution daily.
D. Debride per wound order.
✅ Answer: C
Rationale: Cytotoxic solutions damage granulation tissue. Recognize inappropriate wound product use.
During SBAR handoff, the outgoing nurse omits recent lab results. Which action ensures patient safety?
A. Ask for clarification before accepting report.
B. Review labs after report independently.
C. Proceed and check later.
D. Notify charge nurse of poor handoff.
✅ Answer: A
Rationale: Closed-loop communication requires real-time clarification to prevent errors.
A patient with left-sided heart failure produces pink frothy sputum and has crackles. Which order should the nurse anticipate?
A. Administer IV furosemide.
B. Increase fluid intake.
C. Decrease oxygen flow.
D. Encourage ambulation.
✅ Answer: A
Rationale: Pulmonary edema → reduce preload via diuretics; stabilizes oxygenation.
A nurse prepares to assess pain in a confused older adult with dementia. Which method is most appropriate?
A. Ask the patient to rate pain on a 0–10 scale.
B. Observe facial expressions and body movements.
C. Ask family if the patient usually complains.
D. Document “unable to assess.”
✅ Answer: B
Rationale: In cognitively impaired clients, use behavioral indicators (grimacing, restlessness) to assess pain.
A client with obstructive sleep apnea refuses CPAP use. Which nursing cue has highest safety priority?
A. Daytime fatigue
B. Morning headache
C. Witnessed apneic episodes
D. Sore throat from mask
✅ Answer: C
Rationale: Apneic spells = acute airway risk. Recognize cues for potential hypoxemia → intervene early.
A client with Stage III pressure injury shows decreasing exudate and pink granulation. The nurse evaluates this as:
A. Infection.
B. Healing.
C. Maceration.
D. Ischemia.
✅ Answer: B
Rationale: Pink, moist tissue = healthy healing. Use wound-bed cues for progress evaluation.
When teaching wound care to a client with low literacy, which strategy promotes retention?
A. Provide written pamphlets.
B. Ask for teach-back demonstration.
C. Speak slowly using medical terms.
D. Have the family explain later.
✅ Answer: B
Rationale: Teach-back confirms comprehension regardless of literacy level.
A post-op patient suddenly develops dyspnea, tachycardia, and chest pain.
A. Encourage coughing and deep breathing.
B. Administer oxygen and raise HOB.
C. Start IV fluids rapidly.
D. Place patient in Trendelenburg position.
✅ Answer: B
Rationale: Suspected PE → airway and oxygenation priority.
A client on PCA morphine is found diaphoretic and unresponsive, machine showing multiple activations. Which intervention demonstrates correct judgment?
A. Turn off PCA, assess airway, prepare naloxone.
B. Notify provider first.
C. Reduce PCA dose for next shift.
D. Encourage deep breathing.
✅ Answer: A
Rationale: Cue = PCA overuse → opioid overdose. Prioritize airway, stop exposure, antidote administration.
A client on corticosteroids reports insomnia. Which cue demands provider notification?
A. Mild fatigue during the day
B. Blood glucose 210 mg/dL
C. Difficulty falling asleep
D. Nightmares
✅ Answer: B
Rationale: Hyperglycemia = adverse steroid effect requiring provider follow-up; sleep issues secondary.
Which task can the nurse safely delegate to an experienced UAP caring for a patient with pressure injury?
A. Repositioning every 2 hours.
B. Assessing wound drainage.
C. Selecting dressing type.
D. Teaching skin hygiene.
✅ Answer: A
Rationale: Delegation = routine, low-risk activity; assessment and education remain RN duties.
After a fall, the nurse completes an incident report. What’s the correct documentation in the chart?
A. “Incident report completed.”
B. “Client found on floor, denies injury; provider notified.”
C. “Fall occurred, report filed.”
D. “Client fell due to unsteady gait.”
✅ Answer: B
Rationale: Document objective facts and actions; never mention the incident report.
A client on 4 L O₂ via nasal cannula reports nosebleeds. What is the most appropriate action?
A. Stop oxygen immediately.
B. Add humidification to oxygen delivery.
C. Switch to partial rebreather mask.
D. Lower flow rate to 1 L.
✅ Answer: B
Rationale: Prolonged dry flow irritates mucosa; humidifier prevents epistaxis.
A nurse receives report: “Client reports pain 9/10 after PRN dose 1 hour ago.” What’s the most critical follow-up?
A. Reassess pain intensity and characteristics.
B. Give another PRN dose early.
C. Contact provider for long-acting medication.
D. Document and monitor.
✅ Answer: A
Rationale: Must verify type, quality, and response before escalation. Reassess before action = clinical reasoning integrity.
After teaching about sleep hygiene, which statement indicates need for more instruction?
A. “I’ll exercise right before bedtime.”
B. “I’ll dim the lights an hour before bed.”
C. “I’ll limit caffeine in the afternoon.”
D. “I’ll use my bedroom only for rest.”
✅ Answer: A
Rationale: Evening exercise increases arousal, delaying onset. Misapplication of intervention = ineffective self-care.
During sterile dressing change, the nurse’s glove touches the bed rail. What’s the correct action?
A. Continue since field intact.
B. Replace glove immediately.
C. Discard entire tray.
D. Document contamination.
✅ Answer: B
Rationale: Contamination compromises asepsis. Recognize subtle breach → corrective action maintains safety.
Which nursing note reflects complete and accurate documentation?
A. “Patient resting comfortably.”
B. “Administered 2 mg IV morphine at 1400; pain decreased from 8/10 to 3/10 at 1430.”
C. “Pain medication effective.”
D. “Patient’s pain resolved.”
✅ Answer: B
Rationale: Includes intervention, time, and outcome—meets legal and clinical standards.
A chest tube patient reports shortness of breath. Water seal shows no fluctuation, drainage minimal for 2 hrs.
A. Check tubing for kinks or obstruction.
B. Increase suction level.
C. Strip the chest tube vigorously.
D. Document and reassess in 4 hours.
✅ Answer: A
Rationale: Cue = obstruction—correct immediately to restore lung re-expansion and prevent tension pneumothorax.