aclients postoperative pain seems to be getting worse instead of better whenthe nurse asks the client why do y o u think its getting worse the client

NCLEX-PN

Nclex Questions Management of Care

1. When a client's postoperative pain seems to be getting worse due to grief over the recent death of their spouse, what should the nurse consider?

A. calling the physician for an increased dosage of pain medication
B. calling the physician for a sedative
C. referring the client for a psychiatric consult
D. developing interventions for grief and loss

Correct answer: D

Rationale: The correct answer is developing interventions for grief and loss. In this scenario, the client's pain is not solely sensory but also affective due to grieving over the death of their spouse. It is essential to address the emotional component of pain by providing support and interventions for grief and loss. Referring the client for a psychiatric consult may not be necessary as grieving is a normal response to such a significant loss. Calling the physician for an increased dosage of pain medication or a sedative solely focuses on the sensory aspect of pain and does not address the underlying emotional distress.

2. When are pressure ulcers most likely to occur?

A. when clients are left in one position in bed for extended periods of time.
B. when clients are underweight.
C. when clients are overweight.
D. only in underweight and overweight clients.

Correct answer: A

Rationale: Pressure ulcers usually occur over bony prominences and are caused by decreased circulation. The client who is left in one position in bed for extended periods of time is more prone to decreased circulation to an area of the body and to acquiring a pressure ulcer. Choices B and C are incorrect as pressure ulcers are not exclusive to underweight or overweight clients. The key factor is prolonged pressure on the skin, not the weight of the client. Therefore, the correct answer is that pressure ulcers are most likely to occur when clients are immobilized in one position for extended periods of time.

3. An LPN is working on the care plan for a client with diabetes mellitus. Which of these outcomes would be the most appropriate?

A. The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.
B. The client will maintain a blood glucose level within normal range limits today.
C. The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.
D. The client will maintain a blood glucose level within normal limits throughout my shift.

Correct answer: C

Rationale: The correct answer is 'The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.' This outcome is specific, measurable, and aligns with the goal of managing diabetes mellitus. Choice A is correct because it provides a clear target range (70-110) and includes adherence to facility policy, making it precise and goal-oriented. Choice B lacks specificity on the timeframe, and Choice D is vague in defining the target blood glucose range. In nursing care plans, outcomes should be well-defined, achievable, and measurable to effectively monitor the client's progress in managing their condition.

4. The LPN is assisting the client with an NG tube with activities of daily living. Which of these statements would indicate a need for teaching reinforcement?

A. "Since I'm not eating or drinking by mouth, I do not need to brush my teeth as often."?
B. "I should remain sitting up at a 45-degree angle or higher for 30 minutes after a feeding."?
C. "I can clean around the tube with water and mild soap."?
D. "I should avoid using Vaseline around the nostril and tube."?

Correct answer: A

Rationale: The correct answer is, "Since I'm not eating or drinking by mouth, I do not need to brush my teeth as often."? This statement indicates a need for teaching reinforcement because even when an NG tube is in place, the client should still brush their teeth twice daily. Good oral hygiene is essential to reduce the risk of introducing bacteria that may cause an infection. Choice B is incorrect because remaining sitting up at a 45-degree angle or higher for 30 minutes after a feeding is a correct statement regarding NG tube care, promoting proper digestion and reducing the risk of aspiration. Choice C is also incorrect because cleaning around the tube with water and mild soap is an appropriate practice to maintain cleanliness and prevent infection. Choice D is incorrect because advising to avoid using Vaseline around the nostril and tube is a proper instruction to prevent skin breakdown, occlusion of the tube, and potential aspiration of Vaseline into the lungs.

5. A test that can correctly identify those who do not have a given disease is:

A. specific.
B. sensitive.
C. negative culture.
D. marginal finding.

Correct answer: A

Rationale: The correct answer is 'specific.' A specific test correctly identifies individuals who do not have a particular disease. In this case, since the lab culture report is negative for the suspected infection, it means the test is good at ruling out the disease. 'Sensitive' (choice B) would be incorrect as sensitivity refers to a test's ability to correctly identify individuals who do have the disease. 'Negative culture' (choice C) is incorrect as it describes the result rather than the test's characteristic. 'Marginal finding' (choice D) is unrelated to the concept of correctly identifying individuals without the disease.