The nurse enters the client's room to administer medication. Which of the following should the nurse do
first?
A. Identify the client
B. Lower the bedrail
C. Provide for privacy
D. Wash his hands - CORRECT ANSWERS✅✅Correct answer: D
The nurse should wash his hands prior to touching the client or any of the client's equipment
The nurse is assessing the dorsalis pedis pulses on an 88-year-old client. The nurse notes the feet to be
cool and assesses weak, thready pulses. What action should the nurse take?
A. Assess the popliteal and femoral pulses
B. Assess a 1-minute apical pulse
C. Notify the physician STAT
D. Apply a warm pack and provider reassess in 20 minutes - CORRECT ANSWERS✅✅Correct answer: A
Completing an assessment of other peripheral pulses will provide further data about the adequacy of
circulation to the legs.
The clinic nurse is reviewing the blood pressure readings from the client's home self-monitoring device.
The client states "Look, yesterday my blood pressure jumped up to 150/90 mm Hg. I should be taking
more medicine." What is the nurse's best response?
A. "Yes, that is dangerously high. What were you doing?"
B. "Yes, I'm sure your provider will want to increase the dose."
C. "The doctor will first look at the pattern of your results."
D. "Don't worry. I'm sure it's just because you were stressed." - CORRECT ANSWERS✅✅Correct
answer: C
, It is important for the nurse to complete client teaching about the necessity to look at trends/patterns
of the readings, rather than a one-time elevation.
Which of the following is a psychological response to pain?
Anxiety
Increased blood pressure
Constricted pupils
Increased heart rate - CORRECT ANSWERS✅✅Answer: A
Anxiety is a psychological response to pain. Other psychological responses include anger, depression,
fear, and irritability
The nurse is assessing the confused client. How should the nurse assess the client's pain?
A. Document that it is impossible to assess client's pain due to client's confusion
B. Observe the client carefully for changes in behavior or vital signs
C. Ask the client's family how much pain the client normally has
D. Use only pain scales that feature numbers or "faces" the client can point to - CORRECT
ANSWERS✅✅Correct answer: B
The nurse should observe the confused client for nonverbal cues to pain.
Mr. Baka's chronic cancer pain has recently increased, and he asks the home health nurse what can be
done. The patient is receiving long-acting morphine twice daily. Which of the following is an appropriate
response by the nurse?
A. "If you take more morphine, it will not change your pain relief."
B. "I'll call the physician and ask for an increased dose."
C. "The amount you are taking now is all I can give you."
D. "I'm worried if we increase your dose that you will stop breathing." - CORRECT ANSWERS✅✅Correct
answer: B