the nurse is assessing the client recently returned from surgery the nurse is aware that the best way to assess pain is to
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Nursing Elites

NCLEX-PN

Nclex Practice Questions 2024

1. The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to:

Correct answer: B

Rationale: The best way to evaluate pain levels is to ask the client to rate his pain on a scale. This method provides a more standardized and quantifiable measure of pain compared to subjective observations like facial expressions (choice C) or direct questioning (choice D). Monitoring vital signs (choice A) can be part of pain assessment but is not as specific or reliable as asking the client to self-report pain intensity.

2. Support-system enhancement includes all of the following except:

Correct answer: C

Rationale: Support-system enhancement involves various strategies to strengthen the support system. Determining the barriers to using support systems, discussing ways to help others who are concerned, and involving spouse, family, and friends in the care and planning are all essential aspects of enhancing the support system. However, exploring the life problems of the support-team members is not directly related to enhancing the support system. This approach could potentially invade personal boundaries and may not be necessary for improving the support system, making it the correct answer in this case. Therefore, option C is the correct answer as it does not align with the appropriate methods of support-system enhancement.

3. To decrease a client's use of denial and increase the client's expression of feelings, what should the nurse do?

Correct answer: B

Rationale: The most appropriate approach to decrease a client's use of denial and promote the expression of feelings is to positively reinforce each expression of feelings. This method helps the client feel supported and validated, encouraging them to continue expressing their emotions openly. Positively reinforcing the expression of feelings can help reduce the need for denial as the client learns that their emotions are acknowledged and accepted. Choices A, C, and D are incorrect. Choice A of telling the client to stop using denial is too directive and may be ineffective. Instructing the client to express feelings (Choice C) lacks positive reinforcement, and challenging the client each time denial is used (Choice D) can create a confrontational environment that hinders therapeutic progress.

4. A woman asks, "How much alcohol can I safely drink while pregnant?"? The nurse's best response is:

Correct answer: A

Rationale: The correct answer is, "The amount of alcohol that is safe during pregnancy is unknown."? It is crucial for pregnant women to avoid alcohol as there is no known safe amount during pregnancy. Consuming any amount of alcohol can harm the developing fetus and increase the risk of fetal alcohol syndrome, a condition characterized by mental and physical abnormalities in infants. Choices B, C, and D are incorrect because they provide misleading information that can potentially harm the fetus. Pregnant women should abstain from alcohol to ensure the health and well-being of their baby.

5. The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery?

Correct answer: B

Rationale: The correct answer is B: Contact lenses. It is crucial to remove contact lenses before surgery to prevent corneal drying, especially with non-extended wear lenses. Leaving the hearing aid or artificial eye in place does not pose harm to the client during surgery. While wedding rings are typically covered with tape, leaving them on is acceptable. Therefore, choices A, C, and D are incorrect in this scenario.

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