Question

A nurse is caring for a client who uses a fentanyl transdermal patch to treat chronic pain and is experiencing breakthrough pain following a surgical procedure. Which of the following medications should the nurse expect to administer?

Answer 1

Correct Answers:

Oxycodone

Rationale :

💊 Breakthrough pain is a sudden, temporary flare-up of pain that occurs despite ongoing use of long-acting analgesics like a fentanyl patch.

💊 Oxycodone, a short-acting opioid analgesic, is commonly prescribed in addition to long-acting opioids to manage breakthrough pain.

💊 It works quickly to provide supplemental relief, especially after procedures or during pain spikes, and can be adjusted based on pain intensity.

💊 Other medications listed (e.g., sumatriptan, alprazolam, midazolam) are not used for surgical or breakthrough pain—they treat migraines, anxiety, or sedation.

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Answer 2

Correct Answers:

Bath clients using a chlorhexidine solution.

Rationale :

🧴 The National Patient Safety Goals (NPSGs) set by The Joint Commission include strategies to reduce health care–associated infections (HAIs), especially those related to surgical procedures and invasive devices.

🧴 Bathing clients with chlorhexidine gluconate (CHG) has been shown to reduce the bacterial load on the skin, lowering the risk of bloodstream infections and surgical site infections.

🧴 This practice is especially important before surgeries, in ICU settings, and for clients with central lines or other high-risk devices.

🧴 Incorporating CHG bathing into routine care supports infection prevention and aligns with evidence-based protocols.

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Answer 3

Correct Answers:

Vancomycin-resistant enterococci (VRE)
Methicillin-resistant Staphylococcus aureus (MRSA)
Clostridium difficile

Rationale :

✅ Vancomycin-resistant enterococci (VRE)

🔶 VRE is a multidrug-resistant organism that spreads via direct or indirect contact with contaminated hands or surfaces.

🔶 Contact precautions are essential to prevent transmission, especially in healthcare environments where clients are immunocompromised or have invasive devices.

🔶 Gown and gloves must be worn when entering the room, and dedicated equipment should be used for each client.

🔶 Hand hygiene with alcohol-based sanitizer or soap and water is required before and after contact.

✅ Methicillin-resistant Staphylococcus aureus (MRSA)

🔷 MRSA is a highly contagious bacteria that resists many antibiotics, including methicillin.

🔷 Contact precautions help contain the organism, especially when present in wounds, sputum, or on the skin.

🔷 Gloves and gowns are required before room entry, and care equipment must not be shared between clients.

🔷 Handwashing is critical, especially after touching potentially contaminated surfaces or body fluids.

✅ Clostridium difficile (C. difficile)

🟤 C. difficile causes infectious diarrhea and spreads via spores that resist alcohol-based sanitizers.

🟤 Contact isolation is crucial to prevent transmission via contaminated surfaces or healthcare workers’ hands.

🟤 Soap and water hand hygiene is mandatory, as alcohol sanitizers are ineffective against spores.

🟤 Environmental cleaning with sporicidal agents (e.g., bleach) is required to disinfect surfaces.

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Answer 4

Correct Answers:

Maintaining security of client information is a concern with EHRs.

Rationale :

🔷 Electronic Health Records (EHRs) contain sensitive personal and medical data, making security and confidentiality major concerns in clinical settings.

🔷 HIPAA regulations require strict access controls, encryption, and secure authentication methods to protect client information stored in EHRs.

🔷 Healthcare workers must be trained to log off when not using the system, avoid sharing passwords, and report breaches promptly.

🔷 While EHRs improve care efficiency, they are vulnerable to cyberattacks, unauthorized access, and data leaks, reinforcing the need for strong security protocols.

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Answer 5

Correct Answers:

Tie the restraint to a moveable part of the client's bed frame.

Rationale :

🔹 Restraints must be tied to a moveable part of the bed frame, never to side rails or fixed structures, to prevent injury if the bed is repositioned.

🔹 This placement allows the bed to move safely without placing tension or strain on the client’s body.

🔹 Quick-release knots (not double knots) should be used so restraints can be removed swiftly in an emergency.

🔹 The client must also be monitored at least every 15 to 30 minutes, and offered food, fluids, toileting, and repositioning every 2 hours, not 4.

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Answer 6

Correct Answers:

“Would you like to abstain from meat on Fridays?"

Rationale :

🟢 Lent is a Christian observance, especially among Roman Catholics, Eastern Orthodox, and some Protestant denominations, marked by prayer, fasting, and sacrifice.

🟢 Many individuals abstain from eating meat on Fridays during Lent as part of their religious tradition.

🟢 Asking this question demonstrates cultural and spiritual sensitivity and helps incorporate religious preferences into the plan of care.

🟢 It is non-assumptive and specific, allowing the client to express their personal practice rather than the nurse making broad generalizations.

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Answer 7

Correct Answers:

"Keep a record of cues that trigger a desire to eat.”

Rationale :

🌿 Self-awareness of eating triggers is a key principle in a wellness approach to nutrition. By identifying emotional, environmental, or situational cues that lead to overeating, clients can develop healthier responses.

🌿 Food journals or trigger logs help clients track when and why they eat, promoting mindful eating and behavior change.

🌿 This approach encourages personal accountability and insight, which are essential for long-term wellness and weight management.

🌿 It supports preventive care by addressing behaviors before they result in excessive caloric intake or obesity-related conditions.

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Answer 8

Correct Answers:

"I am not even sure why I exist."

Rationale :

🌙 This statement reflects a loss of meaning and purpose, which is a key indicator of spiritual distress. Clients experiencing spiritual distress often question their existence, values, beliefs, or connection with a higher power.

🌙 It suggests an internal conflict related to the client’s sense of identity, worth, or spiritual beliefs, which may be intensified by depression.

🌙 Spiritual distress can hinder coping and healing, so identifying this statement allows the nurse to initiate spiritual support or chaplain referral.

🌙 The nurse should assess for additional signs like hopelessness, guilt, alienation from faith, or anger toward a higher power.

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Answer 9

Correct Answers:

Presence of crystals

Rationale :

💠 Crystals in the urine can be associated with urinary tract infections (UTIs), particularly when they are accompanied by symptoms like dysuria (painful urination).

💠 Crystals may form due to bacterial activity, changes in urine pH, or as a result of infection-related inflammation, potentially contributing to irritation and discomfort.

💠 Although crystals can also be seen with other conditions (like kidney stones), in a symptomatic client, their presence supports the possibility of infection or irritation within the urinary tract.

💠 Additional UTI indicators may include positive nitrites, leukocyte esterase, and bacteria, but the presence of crystals helps reinforce diagnostic suspicion when other signs are present.

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Answer 10

Correct Answers:

NPWT promotes drainage of infectious materials from the wound.

Rationale :

🧲 Negative Pressure Wound Therapy (NPWT) uses controlled suction to draw out fluid, exudate, and infectious materials from the wound, helping to reduce bioburden.

🧲 The therapy promotes wound healing by maintaining a moist wound environment, reducing edema, and stimulating granulation tissue formation, not reducing it.

🧲 The system does not push air into the wound; rather, it creates a vacuum that helps close the wound edges.

🧲 NPWT also enhances perfusion and cell proliferation, supporting tissue regeneration in chronic or complex wounds.

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QLexNursing

1 :
A nurse is caring for a client who uses a fentanyl transdermal patch to treat chronic pain and is experiencing breakthrough pain following a surgical procedure. Which of the following medications should the nurse expect to administer?

2 :
A nurse is teaching about applying the National Patient Safety Goals to reduce health care-associated infections in clients. Which of the following information should the nurse include in the teaching?

3 :
An employee health nurse is providing an in-service on infection control procedures. Which of the following infections should the nurse identify as requiring contact isolation precautions? (Select all that apply

4 :
A charge nurse is planning a presentation about electronic health records (EHR) for a group of newly licensed nurses. Which of the following information should the nurse include?

5 :
A nurse is applying a belt restraint to a client. Which of the following actions should the nurse take?

6 :
A nurse in a long-term care facility is performing an admission assessment on a client who reports that they are currently observing Lent. Which of the following questions should the nurse ask the client to identify ways to accommodate their religious practices in their plan of care?

7 :
A nurse is discussing a wellness approach to preventing excessive nutrition intake with a group of clients. Which of the following statements should the nurse make?

8 :
A nurse at a mental health clinic is interviewing a client who has depressive disorder and identified as religious during intake. Which of the following client statements should the nurse identify as indicating spiritual distress?

9 :
A nurse is reviewing the urinalysis report for a client who reports dysuria. Which of the following findings should the nurse identify as a manifestation of a urinary tract infection (UTI)?

10 :
A nurse is providing teaching about negative pressure wound therapy (NPWT) to a client who has a chronic pressure ulcer. Which of the following information should the nurse include?

QLexNursing

1 : A nurse is caring for a client who uses a fentanyl transdermal patch to treat chronic pain and is experiencing breakthrough pain following a surgical procedure. Which of the following medications should the nurse expect to administer?

2 : A nurse is teaching about applying the National Patient Safety Goals to reduce health care-associated infections in clients. Which of the following information should the nurse include in the teaching?

3 : An employee health nurse is providing an in-service on infection control procedures. Which of the following infections should the nurse identify as requiring contact isolation precautions? (Select all that apply

4 : A charge nurse is planning a presentation about electronic health records (EHR) for a group of newly licensed nurses. Which of the following information should the nurse include?

5 : A nurse is applying a belt restraint to a client. Which of the following actions should the nurse take?

6 : A nurse in a long-term care facility is performing an admission assessment on a client who reports that they are currently observing Lent. Which of the following questions should the nurse ask the client to identify ways to accommodate their religious practices in their plan of care?

7 : A nurse is discussing a wellness approach to preventing excessive nutrition intake with a group of clients. Which of the following statements should the nurse make?

8 : A nurse at a mental health clinic is interviewing a client who has depressive disorder and identified as religious during intake. Which of the following client statements should the nurse identify as indicating spiritual distress?

9 : A nurse is reviewing the urinalysis report for a client who reports dysuria. Which of the following findings should the nurse identify as a manifestation of a urinary tract infection (UTI)?

10 : A nurse is providing teaching about negative pressure wound therapy (NPWT) to a client who has a chronic pressure ulcer. Which of the following information should the nurse include?

1 :
A nurse is caring for a client who uses a fentanyl transdermal patch to treat chronic pain and is experiencing breakthrough pain following a surgical procedure. Which of the following medications should the nurse expect to administer?

2 :
A nurse is teaching about applying the National Patient Safety Goals to reduce health care-associated infections in clients. Which of the following information should the nurse include in the teaching?

3 :
An employee health nurse is providing an in-service on infection control procedures. Which of the following infections should the nurse identify as requiring contact isolation precautions? (Select all that apply

4 :
A charge nurse is planning a presentation about electronic health records (EHR) for a group of newly licensed nurses. Which of the following information should the nurse include?

5 :
A nurse is applying a belt restraint to a client. Which of the following actions should the nurse take?

6 :
A nurse in a long-term care facility is performing an admission assessment on a client who reports that they are currently observing Lent. Which of the following questions should the nurse ask the client to identify ways to accommodate their religious practices in their plan of care?

7 :
A nurse is discussing a wellness approach to preventing excessive nutrition intake with a group of clients. Which of the following statements should the nurse make?

8 :
A nurse at a mental health clinic is interviewing a client who has depressive disorder and identified as religious during intake. Which of the following client statements should the nurse identify as indicating spiritual distress?

9 :
A nurse is reviewing the urinalysis report for a client who reports dysuria. Which of the following findings should the nurse identify as a manifestation of a urinary tract infection (UTI)?

10 :
A nurse is providing teaching about negative pressure wound therapy (NPWT) to a client who has a chronic pressure ulcer. Which of the following information should the nurse include?