Question

In providing care to a client with chronic pain, which of the following characteristics or client responses should the nurse expect?

Answer 1

Correct Answers:

Heart rate, blood pressure, and pulse rate may be normal while the client is experiencing pain.

Rationale :

✅Chronic pain often leads to desensitization of the sympathetic nervous system, resulting in normal vital signs even when the client reports ongoing discomfort. ✅Unlike acute pain, chronic pain does not always produce physiological stress responses. ✅ The absence of autonomic signs does not negate the presence of pain; nurses must rely on client statements and functional limitations to assess chronic pain accurately.

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Answer 2

Correct Answers:

Stage Ill

Rationale :

💥Stage III pressure ulcers are characterized by full-thickness skin loss that extends into the subcutaneous tissue without exposure of muscle, tendon, or bone. 💥The presence of slough, undermining, and a wound depth of 1.5 cm indicates significant tissue destruction. 💥This stage requires thorough wound care and monitoring for infection and healing progress.

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Answer 3

Correct Answers:

Vitamin A

Rationale :

✅Vitamin A is essential for immune function, skin integrity, and epithelial tissue repair. ✅Clients with acute pancreatitis often have impaired fat digestion due to pancreatic enzyme deficiency, leading to malabsorption of fat-soluble vitamins (A, D, E, K). ✅Supplementing Vitamin A supports tissue healing and prevents deficiencies that could worsen recovery.

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Answer 4

Correct Answers:

Flush the NG feeding tube with 30 ml of water immediately following medication administration

Rationale :

💥Flushing the NG tube with 30 mL of water after giving medications ensures the complete dose reaches the stomach and reduces the risk of tube obstruction from residual medication. 💥It also helps maintain patency and prevents interaction between medications and enteral formula. 💥This step is part of safe medication administration in clients with enteral feeding.

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Answer 5

Correct Answers:

Remain with the client for the first 15 minutes of the transfusion.

Rationale :

✅The initial 15 minutes of a blood transfusion are the highest risk period for developing acute transfusion reactions, such as febrile or hemolytic reactions. ✅Staying with the client allows the nurse to detect early signs (e.g., fever, chills, back pain) and take immediate action to prevent life-threatening complications. ✅Vigilance during this time is a safety priority.

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Answer 6

Correct Answers:

Parenteral nutrition formula

Rationale :

💥Parenteral nutrition has high osmolarity due to its concentrated glucose, protein, and electrolyte content. 💥 Administering it through a peripheral vein risks vein irritation, infiltration, and thrombophlebitis. 💥A central venous catheter is necessary to deliver these solutions safely into larger blood vessels where rapid dilution reduces complications.

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Answer 7

Correct Answers:

Pressure ulcers
Contractures of the extremities
Crackles in the lungs

Rationale :

💥 Pressure ulcers: Immobility leads to unrelieved pressure on bony prominences, compromising blood flow and tissue viability, resulting in skin breakdown. 💥 Contractures of the extremities: Disuse of joints and muscles causes shortening and tightening, leading to decreased range of motion and deformity. 💥 Crackles in the lungs: Reduced movement diminishes lung expansion and mucociliary clearance, causing retained secretions and atelectasis, which manifest as crackles on auscultation.

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Answer 8

Correct Answers:

"l watch television until I fall asleep at night?'

Rationale :

✅Watching television or using electronics before bed interferes with melatonin release due to screen light exposure, delaying sleep onset and reducing overall sleep quality. ✅This statement reflects a need for education on proper sleep hygiene practices, such as limiting stimulation before bedtime.

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Answer 9

Correct Answers:

Change the patient's position every 2 hours, avoiding the supine position.

Rationale :

💥Frequent repositioning relieves pressure on vulnerable skin areas like the sacrum and coccyx, enhancing circulation and preventing ulcer progression 💥Avoiding the supine position reduces pressure directly on the existing stage II ulcer, promoting healing and preventing further tissue breakdown.

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Answer 10

Correct Answers:

Vastus lateralis

Rationale :

💥The vastus lateralis is the preferred IM site for infants and toddlers due to its muscle mass, accessibility, and distance from major nerves and blood vessels. 💥Other sites like the deltoid and gluteus are less developed or carry higher risk in this age group. 💥This choice ensures effective medication absorption and reduces the risk of injury.

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QLexNursing

1 : In providing care to a client with chronic pain, which of the following characteristics or client responses should the nurse expect?

3 : A nurse is providing discharge teaching for a client who has acute pancreatitis and has a prescription for fat-soluble vitamin supplements. The nurse should instruct the client to take a supplement for which of the following?

4 : A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?

5 : A nurse is preparing to administer a unit of packed red blood cells to a client. Which of the following actions should the nurse plan to take?

6 : Which fluid or product to be infused requires a central venous access rather than a peripheral access?

7 : A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select all that apply.)

8 : A nurse is instructing a young adult client about healthful sleep habits. Which of the following statements should the nurse identify as an Indication that the client needs further teaching?

9 : A chronically ill, bedfast patient cared for in the home by family members has a stage II pressure ulcer over the coccyx. To prevent further tissue damage, the home care nurse instructs the family members that it is most important to

10 : What is the preferred 1M injection site for a I-year-old?