Comfort/Pain
Which client statement requires immediate follow-up?
A. "I take acetaminophen for headaches."
B. "I drink several alcoholic beverages each day while taking acetaminophen."
C. "I use the dosing syringe to give acetaminophen to my child."
D. "I check medication labels for acetaminophen."
What is...
B. "I drink several alcoholic beverages each day while taking acetaminophen."
A nurse is assessing pain in a 2-year-old child after surgery. Which pain assessment tool should the nurse use?
What is...
A FLACC Pain Scale
The FLACC (Face, Legs, Activity, Cry, Consolability) scale is recommended for infants, toddlers, and children who are unable to reliably self-report pain.
Which laboratory value requires the closest monitoring during the first several days of TPN therapy?
A. Platelet count
B. Blood glucose
C. Hemoglobin
D. White blood cell count
What is...
B. Blood glucose
Which client is the best candidate for enteral nutrition?
A. Client with a bowel obstruction
B. Client with severe pancreatitis requiring complete bowel rest
C. Client with an ischemic bowel
D. Client with dysphagia following a stroke whose gastrointestinal tract is functioning
What is...
D. Client with dysphagia following a stroke whose gastrointestinal tract is functioning
Which assessment finding requires the nurse to withhold a scheduled dose of morphine?
A. Pain score of 8/10
B. Respiratory rate of 10 breaths/min with excessive drowsiness
C. Blood pressure of 138/84 mm Hg
D. Mild nausea
What is...
B. Respiratory rate of 10 breaths/min with excessive drowsiness
The nurse is caring for four clients, and each is complaining of pain. Which client would the nurse determine is experiencing chronic pain?
A. A client who reports severe incisional pain 24 hours after abdominal surgery.
B. A client who has burning pain from diabetic neuropathy that has persisted for the past 8 months.
C. A client who reports sudden right lower quadrant abdominal pain that began 2 hours ago.
D. A client with a fractured femur who reports sharp pain immediately following the injury.
What is...
B. A client who has burning pain from diabetic neuropathy that has persisted for the past 8 months.
A client describes pain as "burning and electric shocks" in both feet related to diabetes. Which type of pain is this?
A. Somatic
B. Visceral
C. Neuropathic
D. Referred
What is...
C. Neuropathic
A client is receiving continuous enteral tube feedings. Which nursing intervention is most important to reduce the risk of aspiration?
A. Flush the feeding tube every 8 hours.
B. Elevate the head of the bed 30–45° during feedings and for at least 30–60 minutes afterward.
C. Restrict fluid intake.
D. Administer feedings as rapidly as tolerated.
What is...
B. Elevate the head of the bed 30–45° during feedings and for at least 30–60 minutes afterward.
A postoperative client has poor appetite. Which intervention is most appropriate?
A. Offer three large meals daily.
B. Encourage nutrient-dense, high-protein foods in small, frequent meals.
C. Restrict snacks between meals.
D. Delay pain medication until after meals.
What is...
B. Encourage nutrient-dense, high-protein foods in small, frequent meals.
A hospitalized 6-year-old is crying and appears anxious before an IV insertion. Which nursing intervention is most appropriate to help manage procedural pain?
A. Tell the child to "be brave" and avoid crying.
B. Delay the procedure until the child stops crying.
C. Use distraction techniques while allowing a parent to remain with the child during the procedure.
D. Explain that the procedure will not hurt.
What is...
C. Use distraction techniques while allowing a parent to remain with the child during the procedure.
A nurse is preparing to assist a client with ambulation following hip replacement surgery. Before getting out of bed, the client states, "My pain is too severe to walk right now." Which action should the nurse take first?
A. Encourage the client to ambulate despite the pain.
B. Assess the client's pain using a validated pain scale.
C. Document the client's refusal to ambulate.
D. Notify the healthcare provider.
What is...
B. Assess the client's pain using a validated pain scale.
Which assessment finding best indicates that a client has developed opioid tolerance?
A. The client experiences anxiety and diaphoresis after missing one dose.
B. The client requests increasingly larger doses to achieve the same pain relief.
C. The client continues taking opioids despite losing employment and family relationships.
D. The client has pinpoint pupils and a respiratory rate of 8 breaths/min.
What is...
B. The client requests increasingly larger doses to achieve the same pain relief.
A nurse is teaching a client about the USDA MyPlate recommendations. Which statement by the client indicates an understanding of the teaching?
A. "Half of my plate should be protein."
B. "I should fill half of my plate with fruits and vegetables."
C. "I should avoid all carbohydrates."
D. "Dairy products should make up half of my meals."
What is...
B. "I should fill half of my plate with fruits and vegetables."
A nurse is developing a nutrition plan for an older adult at risk for malnutrition. Which interventions are appropriate? Select all that apply.
A. ☐ Offer small, frequent meals.
B. ☐ Encourage nutrient-dense, high-protein foods.
C. ☐ Monitor weight trends.
D. ☐ Provide oral care before meals.
E. ☐ Encourage fluid intake throughout the day.
F. ☐ Restrict fluids to reduce nighttime urination.
What is...
A. ☐ Offer small, frequent meals.
B. ☐ Encourage nutrient-dense, high-protein foods.
C. ☐ Monitor weight trends.
D. ☐ Provide oral care before meals.
E. ☐ Encourage fluid intake throughout the day.
A nurse is caring for a client with newly diagnosed chronic kidney disease. The client asks, "What foods should I avoid?" Which healthcare team member should the nurse consult?
A. Speech-language pathologist
B. Occupational therapist
C. Registered dietitian
D. Physical therapist
What is...
C. Registered dietitian
A postoperative client reports pain as 8/10 but is smiling and talking comfortably with family. Which action should the nurse take?
A. Delay pain medication because the client's behavior does not match the reported pain.
B. Reassess the client in 30 minutes.
C. Administer the prescribed analgesic and reassess the client's pain.
D. Ask the family if they believe the client is truly in pain.
What is...
C. Administer the prescribed analgesic and reassess the client's pain.
A nurse is caring for a client who reports postoperative pain of 8/10 despite receiving oral hydrocodone 45 minutes ago. Which nursing action is most appropriate?
A. Document that the medication was ineffective.
B. Reassess the pain, evaluate for side effects, and determine whether additional interventions are indicated.
C. Immediately administer another opioid.
D. Explain that postoperative pain is expected.
What is...
B. Reassess the pain, evaluate for side effects, and determine whether additional interventions are indicated.
A nurse is assessing a hospitalized older adult with a 12-lb (5.4-kg) unintentional weight loss over the past 2 months. Which nursing action is the priority?
A. Request a high-calorie diet.
B. Consult the dietitian.
C. Perform a comprehensive nutritional assessment, including dietary intake, swallowing ability, and recent weight history.
D. Encourage oral nutritional supplements.
What is...
C. Perform a comprehensive nutritional assessment, including dietary intake, swallowing ability, and recent weight history.
Which assessment finding places a client at the highest risk for malnutrition?
A. BMI of 28
B. Intentional 10-lb weight loss through diet and exercise
C. Unintentional 8% weight loss over 2 months
D. Eating three meals daily
What is...
C. Unintentional 8% weight loss over 2 months
he client states:
"I don't want any more pain medicine because I'm afraid I'll become addicted."
What is the nurse's best response?
A. "You won't become addicted."
B. "Most postoperative clients who use opioids as prescribed for short-term pain management do not develop opioid use disorder. Let's discuss your concerns and other ways to manage your pain."
C. "Pain medication isn't necessary if you can tolerate the pain."
D. "You'll recover faster without opioids."
What is...
B. "Most postoperative clients who use opioids as prescribed for short-term pain management do not develop opioid use disorder. Let's discuss your concerns and other ways to manage your pain."
A nurse is caring for four pediatric clients. Which child should the nurse assess first?
A. A 3-year-old with a FLACC score of 8 after surgery
B. A 10-year-old requesting another blanket
C. A 6-year-old watching television and reporting pain of 2/10
D. A 12-year-old asking when lunch will arrive
What is...
A. A 3-year-old with a FLACC score of 8 after surgery
A client with chronic low back pain states, "I just want my pain to be completely gone." Which response by the nurse is most appropriate?
A. "You should expect complete pain relief with treatment."
B. "The primary goal is often to improve your ability to function while reducing pain to a manageable level."
C. "Long-term opioid therapy is the best treatment for chronic pain."
D. "Bed rest is recommended until your pain resolves."
What is...
B. "The primary goal is often to improve your ability to function while reducing pain to a manageable level."
The TPN solution has not yet arrived from the pharmacy, and the current bag will be empty in 15 minutes. What should the nurse do?
A. Stop the infusion until the next bag arrives.
B. Infuse 10% dextrose (D10W) as prescribed or according to institutional policy until the TPN is available.
C. Infuse normal saline.
D. Flush the central line with sterile water.
What is...
B. Infuse 10% dextrose (D10W) as prescribed or according to institutional policy until the TPN is available.
Which clients should the nurse anticipate referring to a registered dietitian? Select all that apply.
A. ☐ A client with newly diagnosed diabetes mellitus requiring meal planning.
B. ☐ A client with dysphagia following a stroke.
C. ☐ A client with severe burns requiring increased protein intake.
D. ☐ An older adult with unintended weight loss and poor appetite.
E. ☐ A client requesting instruction on a heart-healthy diet after a myocardial infarction.
F. ☐ A client needing evaluation of swallowing safety.
What is...
A. ☐ A client with newly diagnosed diabetes mellitus requiring meal planning.
C. ☐ A client with severe burns requiring increased protein intake.
D. ☐ An older adult with unintended weight loss and poor appetite.
E. ☐ A client requesting instruction on a heart-healthy diet after a myocardial infarction.
A nurse is caring for a 76-year-old client admitted with heart failure. Assessment findings include:
Which action should the nurse take first?
A. Encourage the client to finish every meal.
B. Refer the client to the registered dietitian for a comprehensive nutritional assessment.
C. Offer high-calorie snacks twice daily.
D. Begin calorie counts for one week before notifying anyone.
What is...
B. Refer the client to the registered dietitian for a comprehensive nutritional assessment.