Question

A client who is two days post abdominal surgery has been having mild to moderate pain. This evening, the client requests pain medication for severe abdominal pain. Which assessments must the nurse conduct before administering the pain medication? Select all that apply.

Answer 1

Correct Answers:

Abdomen for rigidity.
Aggravating factors.
Last time pain medication was given.
Pain severity

Rationale :

Abdomen for rigidity

🎯New severe postoperative abdominal pain can indicate life-threatening complications such as peritonitis, hemorrhage, or an anastomotic leak, and rigidity/guarding is a classic peritoneal-sign that requires immediate recognition before analgesia.

🎯Assessing for rebound tenderness, distention, hypo/absent bowel sounds, and involuntary guarding helps differentiate surgical abdomen from expected post-op discomfort.

🎯Giving opioids before a focused exam can mask clinical findings, delay diagnosis, and potentially worsen outcomes.

🎯Documenting the exam provides a baseline to trend changes after the medication and guides escalation (labs, imaging, surgical consult).

🎯This action aligns with the nursing principle of assessment before intervention and the rights of medication administration (right indication, right timing).

Aggravating factors

🎯A complete pain assessment incorporates PQRST (Provokes/Palliates, Quality, Region/Radiation, Severity, Time); clarifying aggravating/relieving factors identifies mechanical vs visceral sources and guides drug selection.

🎯Worsening pain with movement, coughing, or oral intake may suggest ileus, obstruction, or leak, prompting cautious opioid use and additional evaluation.

🎯Knowing what relieves the pain (e.g., position change, antiemetics) supports multimodal analgesia and reduces opioid exposure.

🎯This information forms the baseline against which post-medication effectiveness and adverse effects are evaluated.

🎯Thorough characterization of pain improves safety, efficacy, and communication with the surgical team.

Last time pain medication was given

🎯Verifying time, dose, and route prevents dose stacking, sedation/respiratory depression, and analgesic duplication (e.g., multiple opioids or acetaminophen-containing products).

🎯For PRN orders, the nurse must confirm dosing intervals, maximum daily doses, and any recent PCA/nerve block use to uphold the five (ten) rights.

🎯This step reduces adverse drug events and supports medication reconciliation across shifts and transitions of care.

🎯It also informs whether non-opioid adjuncts or nonpharmacologic measures were recently attempted and with what effect.

🎯Accurate timing ensures a safe titration strategy and provides defensible documentation of clinical judgment.

Pain severity

🎯Quantifying intensity using a validated scale (e.g., 0–10 numeric, Wong-Baker) establishes a baseline and guides analgesic choice and initial dose (mild vs moderate/severe pathways).

🎯Severity trending after administration demonstrates response, supports reassessment requirements, and informs rescue dosing or therapy change.

🎯Coupling severity with function-focused goals (e.g., ability to deep breathe, ambulate) operationalizes pain control into measurable outcomes.

🎯Clear documentation enhances team communication, quality metrics, and patient safety, particularly in the early 48-hour post-op window.

🎯Recording severity also assists in identifying disproportionate pain, which may signal complications requiring urgent evaluation.

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Answer 2

Correct Answers:

Measure the calf circumference of both legs.

Rationale :

✔️Measure calf circumferences bilaterally (D): A new unilateral warm, red, painful calf in an immobile older adult is highly suspicious for DVT; serial circumference measurements are the recommended, noninvasive assessment to trend edema/inflammation.

✔️This avoids provoking embolization, which can occur with massage, forced dorsiflexion (Homan’s), or ambulation.

✔️Documentation of asymmetry supports urgent provider notification and possible diagnostic ultrasound/anticoagulation.

✔️It also informs fall and PE risk precautions while definitive testing is arranged.

✔️Safety-first assessment protects the client while you escalate care.

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Answer 3

Correct Answers:

Include extended family members in discharge education and observe the care they provide to the client in the hospital.

Rationale :

✅Include extended family in discharge education and observe their care (D): This respects cultural preferences for family-centered care, enhances caregiver capacity, and aligns with patient- and family-centered nursing.

✅Teach-back with demonstration by each helper lets the nurse validate competence, correct technique, and standardize routines for a paralyzed pediatric client.

✅Early inclusion improves adherence, reduces readmissions, and builds a safe home environment (e.g., transfers, skin care, bowel/bladder, equipment).

✅It also identifies who needs extra training or community resources/home health.

✅The plan becomes culturally congruent and clinically safe—the optimal balance.

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Answer 4

Correct Answers:

Perform an assessment of the client's unaffected extremity.

Rationale :

🔷Assess the unaffected extremity (C) when new heel discomfort is reported: In an immobile client, unexpected contralateral heel pain can signal pressure injury, ischemia, or nerve entrapment; assessment precedes intervention.

🔷Perform a focused exam for color, temperature, capillary refill, pulses, sensation, and skin integrity on the left heel.

🔷Early detection allows you to offload, reposition, and escalate before breakdown occurs.

🔷Continuing with the original limb alone risks missing a preventable injury on the other side.

🔷This approach follows the neurovascular and skin assessment standards for at-risk, immobile patients.

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Answer 5

Correct Answers:

Notify the health care provider (HCP) of the finding.
Ask the client about the effectiveness of medical marijuana.
Include medical marijuana in the clients plan care.

Rationale :

Notify the health care provider (HCP)

🧠Medical marijuana must be part of formal medication reconciliation so the HCP can evaluate drug–drug interactions, especially with antiepileptics that undergo hepatic CYP metabolism (e.g., potential effects on phenytoin levels, sedation, and liver enzymes).

🧠Notifying the HCP supports a coordinated plan to adjust doses, order baseline and follow-up labs (e.g., LFTs, serum antiepileptic levels), and define safety parameters for combined therapy.

🧠In pediatrics, clinician oversight is essential to verify product quality (variable CBD:THC ratios, potency, contaminants) and to align use with evidence-based indications (e.g., cannabidiol products for specific epilepsies) while minimizing harm.

🧠The HCP can also address legal, consent, and documentation requirements, ensuring the family understands storage and access controls to prevent pediatric exposure and diversion.

🧠Early interprofessional notification (HCP–pharmacy–nursing) creates a clear monitoring plan for efficacy, adverse effects, and seizure control, improving safety and outcomes.

Ask the client about the effectiveness of medical marijuana

🧠A therapeutic assessment should capture seizure frequency, duration, recovery time, and triggers (use of a seizure diary) to determine whether cannabis is conferring meaningful clinical benefit.

🧠Clarifying the product type, CBD:THC ratio, dose, route, timing, and consistency of use identifies variability that can explain response or side effects (e.g., somnolence, dizziness, appetite or GI changes).

🧠Exploring functional outcomes—sleep quality, school attendance, mood, and caregiver burden—integrates patient-centered metrics beyond raw seizure counts.

🧠Screening for adverse effects (sedation, cognitive slowing) and safety risks (falls, aspiration during seizures) helps tailor precautions and guides whether dose adjustments or alternative strategies are needed.

🧠These data allow the team to compare current control to baseline, refine the overall seizure-management plan, and decide if ongoing cannabis use remains appropriate and safe.

Include medical marijuana in the plan of care

🧠Listing cannabis as a current therapy in the plan of care ensures transparent documentation, supports consistent handoffs, and allows the team to set monitoring targets (e.g., LFTs, sedation checks, seizure log review).

🧠Nursing actions can incorporate education on safe storage, dosing accuracy, recognition of warning signs (worsening seizures, excessive sedation), and when to seek urgent care.

🧠Integration with pharmacy enables verification of product reliability, discussion of interaction potential with antiepileptics, and reinforcement of no unapproved product changes without clinician input.

🧠The plan should include safety precautions (fall prevention, aspiration readiness), developmentally appropriate teaching, and alignment with school or home routines for dosing and observation.

🧠Embedding cannabis use into the interprofessional plan promotes coordinated, harm-reduction-oriented care, ensuring that benefits are captured and risks are actively mitigated.

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Answer 6

Correct Answers:

5

Rationale :

✍️Dose ordered: 50 mg diphenhydramine PO.

✍️Supply: 10 mg/mL.

✍️Calculation: mL needed

♦️50 ÷ 10

5 mL

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Answer 7

Correct Answers:

The UAP is using the wrong technique.

Rationale :

🟠The described positioning (e.g., client’s foot resting on the caregiver’s chest) suggests poor body mechanics and nonstandard technique, indicating the UAP is using the wrong technique (D) for range-of-motion/assisted exercises.

🟠Proper ROM maintains joint mobility while protecting skin, joints, and staff—feet should be supported neutrally, not against the caregiver’s torso.

🟠Incorrect technique can cause musculoskeletal strain, pain, or skin injury in an older, immobile client.

🟠The nurse should coach/re-educate the UAP using demonstration and return-demo to ensure safe, standardized care.

🟠If pain is observed, pause and perform a quick assessment before resuming with the correct method.

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Answer 8

Correct Answers:

The client's social environment.
The client's poor nutritional intake.
The client's ability to ambulate safely.
Daily intake and output.
Client binge drinking.

Rationale :

The client’s social environment

💧Assess the social supports and living conditions, including caregiver availability, safe housing, and access to clean fluids/food, because dehydration risk is strongly influenced by context.

💧 Identify barriers to adherence (e.g., cost, transport, stigma) and connect the client with community resources such as case management, social work, and home health to sustain recovery.

💧 Screen for alcohol use patterns and triggers at home and discuss relapse prevention, which directly impacts rehydration success and readmission risk.

💧 Incorporate the client’s health literacy and language needs to create clear, teach-back discharge instructions on oral rehydration and warning signs.

💧 A tailored plan that fits the real-life environment improves safety, adherence, and quality of life after discharge.

The client’s poor nutritional intake

💧 Address malnutrition with a stepwise refeeding plan (small, frequent nutrient-dense meals) and emphasize protein and electrolyte replenishment to support healing.

💧 Because of recent binge alcohol use, give thiamine (vitamin B1) before carbohydrate loads to reduce the risk of Wernicke encephalopathy—a critical neuroprotective step.

💧 Monitor for refeeding syndrome (falling phosphate, potassium, magnesium), adjusting the plan if laboratory derangements occur.

💧 Include antiemetic strategies and GI protection if needed to enable oral intake and minimize further fluid loss.

💧 Provide nutrition counseling and a follow-up referral to dietetics to maintain long-term nutritional stability.

The client’s ability to ambulate safely

💧 Evaluate for orthostatic hypotension and gait instability, as dehydration causes volume depletion that increases fall risk.

💧 Implement fall precautions, consider assistive devices, and initiate supervised first ambulation to protect immediate safety.

💧 Reassess vital signs, dizziness, and fatigue during activity; escalate care if symptoms persist despite rehydration.

💧 Teach the client to sit at the bed edge and stand slowly, reinforcing call for assistance before walking.

💧 Safe mobility preserves functional status, reduces injury risk, and supports earlier recovery.

Daily intake and output

💧 Track I&O, daily weight, and urine characteristics (volume, color, specific gravity) to quantify rehydration progress and detect ongoing losses.

💧 Pair I&O with electrolyte monitoring (Na⁺, K⁺, Mg²⁺, phosphate) to guide fluid type (e.g., isotonic vs electrolyte-rich oral solutions) and replacement rates.

💧 Use goal-directed targets (e.g., urine output ≥ 0.5 mL/kg/hr) and adjust therapy to avoid under- or over-correction.

💧 Document trends for team communication and to inform discharge readiness.

💧 At discharge, teach self-monitoring (fluid goals, daily weight checks, when to call) to sustain home safety.

Client binge drinking

💧 Perform screening and brief intervention (e.g., AUDIT-C) and offer referral to treatment, because ongoing alcohol misuse drives recurrent dehydration, malnutrition, and readmissions.

💧 Anticipate and monitor for alcohol withdrawal using a validated scale (e.g., CIWA-Ar), with a plan for symptom-triggered therapy to maintain safety.

💧 Provide harm-reduction counseling (hydration strategies, avoid binge patterns, food before alcohol) and relapse-prevention resources.

💧 Coordinate with social work/addiction services to arrange follow-up, support groups, or medication-assisted treatment when appropriate.

💧 Integrating alcohol-use care into the plan enhances long-term outcomes, stability, and quality of life.

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Answer 9

Correct Answers:

Instruct the client to call for assistance when getting out of bed.

Rationale :

🔵With K⁺ = 3.1 mEq/L and lightheadedness, the immediate safety concern is fall prevention; instruct the client to call for assistance before getting out of bed (D).

🔵Hypokalemia predisposes to weakness, orthostatic symptoms, and dysrhythmias, elevating fall and cardiac risk.

🔵Prompt supervised mobilization allows monitoring for symptoms while you escalate care.

🔵After ensuring safety, collaborate to replace potassium and review diuretic therapy per provider orders.

🔵Document teaching and adherence to the call-don’t-fall plan.

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Answer 10

Correct Answers:

"Please tell me how you are feeling about your new diagnosis."

Rationale :

✔️This open-ended statement promotes therapeutic communication and gives the client an opportunity to express emotions, fears, and perceptions about the new diagnosis.

✔️It demonstrates active listening and respect, addressing the hospital’s concern that nurses were not allowing clients to speak freely.

✔️Encouraging emotional expression helps the nurse identify coping mechanisms, educational needs, and support resources relevant to chronic renal failure.

✔️It also builds trust and rapport, improving client satisfaction and engagement in care planning.

✔️This type of response embodies client-centered care and adheres to the ANA Code of Ethics principle of promoting dignity and autonomy.

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W7 NR226 CJE Fundamentals Benchmark 2551

No.

1 :
A client who is two days post abdominal surgery has been having mild to moderate pain. This evening, the client requests pain medication for severe abdominal pain. Which assessments must the nurse conduct before administering the pain medication? Select all that apply.

2 :
The nurse cares for an immobile, older adult client who was admitted from a long-term care facility. Today, the client reports pain in the left calf. Nursing assessment reveals redness and warmth to the area. How should the nurse proceed with further assessment of the client?

4 :
The nurse performs a neurovascular assessment on a client who is immobile because of a fracture to the right lower extremity when the client says, "I know it's my right leg that is broken, but my left heel sure feels uncomfortable." What is the priority action by the nurse?

5 :
The health history of a young client with a seizure disorder reveals the use of medical marijuana to treat the seizures. When planning care for this client, how should the nurse proceed? Select all that apply.

6 :
Diphenhydramine 50 mg every 4 hours PRN is prescribed orally for a client who has the flu and is coughing. In the medication dispensing system is diphenhydramine 10 mg/mL. How many milliliters (mL) should the nurse administer with each dose? Do not round.

7 :
The nurse instructs the unlicensed assistive personnel (UAP) in the image to ensure that an older adult client, who is immobile but able to?

9 :
The nurse cares for a client who takes a potassium-wasting diuretic. The client's potassium level today is 3.1 (Reference: 3.5-5.2 mEq/L), and the client reports feeling lightheaded when getting out of bed. Which action by the nurse is best to ensure the client's immediate safety?

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W7 NR226 CJE Fundamentals Benchmark 2551

No.

1 : A client who is two days post abdominal surgery has been having mild to moderate pain. This evening, the client requests pain medication for severe abdominal pain. Which assessments must the nurse conduct before administering the pain medication? Select all that apply.

2 : The nurse cares for an immobile, older adult client who was admitted from a long-term care facility. Today, the client reports pain in the left calf. Nursing assessment reveals redness and warmth to the area. How should the nurse proceed with further assessment of the client?

4 : The nurse performs a neurovascular assessment on a client who is immobile because of a fracture to the right lower extremity when the client says, "I know it's my right leg that is broken, but my left heel sure feels uncomfortable." What is the priority action by the nurse?

5 : The health history of a young client with a seizure disorder reveals the use of medical marijuana to treat the seizures. When planning care for this client, how should the nurse proceed? Select all that apply.

6 : Diphenhydramine 50 mg every 4 hours PRN is prescribed orally for a client who has the flu and is coughing. In the medication dispensing system is diphenhydramine 10 mg/mL. How many milliliters (mL) should the nurse administer with each dose? Do not round.

7 : The nurse instructs the unlicensed assistive personnel (UAP) in the image to ensure that an older adult client, who is immobile but able to?

9 : The nurse cares for a client who takes a potassium-wasting diuretic. The client's potassium level today is 3.1 (Reference: 3.5-5.2 mEq/L), and the client reports feeling lightheaded when getting out of bed. Which action by the nurse is best to ensure the client's immediate safety?

1 :
A client who is two days post abdominal surgery has been having mild to moderate pain. This evening, the client requests pain medication for severe abdominal pain. Which assessments must the nurse conduct before administering the pain medication? Select all that apply.

2 :
The nurse cares for an immobile, older adult client who was admitted from a long-term care facility. Today, the client reports pain in the left calf. Nursing assessment reveals redness and warmth to the area. How should the nurse proceed with further assessment of the client?

4 :
The nurse performs a neurovascular assessment on a client who is immobile because of a fracture to the right lower extremity when the client says, "I know it's my right leg that is broken, but my left heel sure feels uncomfortable." What is the priority action by the nurse?

5 :
The health history of a young client with a seizure disorder reveals the use of medical marijuana to treat the seizures. When planning care for this client, how should the nurse proceed? Select all that apply.

6 :
Diphenhydramine 50 mg every 4 hours PRN is prescribed orally for a client who has the flu and is coughing. In the medication dispensing system is diphenhydramine 10 mg/mL. How many milliliters (mL) should the nurse administer with each dose? Do not round.

7 :
The nurse instructs the unlicensed assistive personnel (UAP) in the image to ensure that an older adult client, who is immobile but able to?

9 :
The nurse cares for a client who takes a potassium-wasting diuretic. The client's potassium level today is 3.1 (Reference: 3.5-5.2 mEq/L), and the client reports feeling lightheaded when getting out of bed. Which action by the nurse is best to ensure the client's immediate safety?