Question 1

Which home remedy is suitable to relieve the itching associated with varicella?

Accepted Answer

Answer reason: A baking soda and water paste is a common nonpharmacologic measure that can help calm itching by providing a mildly soothing, drying effect on vesicular lesions. Baby powder can cake in moist lesions and may increase irritation or contamination. Hydrogen peroxide is an irritant to healing tissue and can delay wound healing, so it is not an appropriate home measure for pruritus control.

Question 2

An adolescent who sustained a tibia fracture in a motor vehicle accident has a cast. What should the nurse do to help relieve the itching?

Accepted Answer

Answer reason: Cast care prioritizes relieving discomfort while preventing skin breakdown and infection from moisture or foreign objects under the cast. Cool air reduces heat and itching without introducing liquid that can soften padding and promote maceration. Inserting applicators (even “sterile”) to scratch can abrade skin and create pressure points that may ulcerate under the cast. Applying creams or water under the cast also adds moisture/irritants and increases risk of dermatitis, odor, and infection.

Question 3

The dialysis solution is warmed before use in peritoneal dialysis primarily to?

Accepted Answer

Answer reason: Warming peritoneal dialysate is a comfort and safety measure to reduce abdominal discomfort, cramping, and guarding that can occur when cool fluid enters the peritoneal cavity. Less cramping improves tolerance of the infusion and helps the dwell phase proceed without pain-related complications. Solute clearance (e.g., urea) is driven primarily by diffusion across the peritoneal membrane and concentration gradients, not by warming the bag. It also is not used to shift potassium intracellularly; that is achieved with therapies like insulin/glucose or beta-agonists rather than dialysate temperature.

Question 4

Nathaniel has severe pruritus due to having hepatitis B. What is the best intervention for his comfort?

Accepted Answer

Answer reason: Pruritus with hepatitis is commonly worsened by heat, skin dryness, and irritation, so comfort measures should minimize vasodilation and prevent further skin breakdown. Tepid bathing soothes inflamed nerve endings without the itch-amplifying effects of hot water and is a standard nonpharmacologic approach to generalized itching. Hot water is a frequent distractor because it may feel briefly relieving but typically intensifies pruritus by increasing cutaneous blood flow and drying the skin. Avoiding lotions is incorrect because moisturizers (especially bland, fragrance-free emollients) usually help protect the skin barrier and reduce itching-related excoriations.

Question 5

Nurse Cheryl is assessing Fred, a 14-year-old boy who had scoliosis; besides checking neurologic status directly after Harrington rod instrumentation and spinal fusion, she should be regarded with which of the following factors?

Accepted Answer

Answer reason: This surgery is highly painful due to extensive muscle dissection and bony work, and uncontrolled pain can impair ventilation, mobility, and recovery, and may also mask evolving complications. Evaluating comfort guides timely analgesia, positioning/log-rolling, and nonpharmacologic measures while maintaining spinal alignment. By contrast, diet tolerance and physical therapy planning are important but are typically secondary to immediate post-op pain/comfort and neurologic monitoring, and understanding of the procedure is mainly a preoperative/teaching focus.

Question 6

Which manifestation indicates to the nurse that the pain of a terminally ill nonverbal client is not well managed?

Accepted Answer

Answer reason: Persistent restlessness and frequent leg movement are classic signs of discomfort and can indicate inadequate analgesia or the need to reassess timing/dose/route of pain medications. In contrast, crackles suggest fluid overload/secretions, hyperactive bowel sounds suggest GI stimulation/diarrhea, and reluctance to eat may reflect fatigue, depression, dysphagia, or disease progression rather than pain control. When these behavioral cues persist, the nurse should use a validated behavioral pain scale and promptly collaborate to adjust the pain management plan.

Question 7

The nurse should prevent corneal abrasion in a client with myasthenia gravis by performing which nursing intervention?

Accepted Answer

Answer reason: Dry, poorly lubricated corneal surfaces are prone to epithelial breakdown and abrasion. Frequent lubricating drops maintain a protective tear film and reduce friction from the eyelids and environmental exposure. Saline irrigation is not a routine preventive strategy, contact lenses can worsen dryness and increase abrasion/infection risk, and sunglasses address light sensitivity rather than corneal protection.

Question 8

The nurse is using meditation with a client to help him decrease his pain. Which factor is important to consider when using this type of therapy?

Accepted Answer

Answer reason: Nonpharmacologic pain interventions must be individualized based on the client’s clinical status, cognitive ability, readiness, and symptom burden. Conditions such as acute severe pain, anxiety/panic, delirium, hypoxia, or inability to concentrate can limit effectiveness and may require different timing or alternative techniques. Client-centered care also supports aligning the approach with the client’s preferences and goals rather than a nurse-determined method. Teaching can occur in various settings when the client is stable; it does not inherently require outpatient care or a separate certified instructor to be safe and effective when the nurse is competent to teach it.

Question 9

The home health care nurse is caring for a male client with cancer and the client is complaining of acute pain. The appropriate nursing assessment of the client’s pain would include which of the following?

Accepted Answer

Answer reason: g., 0–10), which supports accurate baseline assessment and ongoing evaluation. This directly captures intensity and guides selection and titration of analgesic and nonpharmacologic interventions. Nonverbal cues can support assessment when communication is limited, but they do not override self-report when the patient can describe pain. A nurse’s impression is vulnerable to bias and is not an appropriate primary measure, and assessing relief after intervention is evaluation rather than the initial pain assessment focus.

Question 10

A client in a long-term care facility complains of pain. The nurse collects data about the client’s pain. The first step in pain assessment is for the nurse to?

Accepted Answer

Answer reason: Pain is subjective, and the patient’s self-report is the most reliable indicator and the foundation of assessment. Accepting the report establishes therapeutic trust and prevents undertreatment, especially when objective signs are absent or incongruent. After acknowledging the report, the nurse then characterizes pain (location, intensity, quality, timing) using a scale to guide interventions and evaluate response. Focusing first on coping methods or a broad “status” statement can delay validating the symptom and does not establish the primary assessment principle.

Question 11

The nurse places an aquathermia pad on a client with a muscle sprain. The nurse informs the client the pad should be removed in 30 minutes. Why will the nurse return in 30 minutes to remove the pad?

Accepted Answer

Answer reason: Prolonged local heat exposure initially increases blood flow, but if applied too long it can trigger a rebound (reflex) increase in perfusion that worsens edema and inflammation, especially in soft-tissue injuries. Limiting application time reduces risk of swelling, tissue damage, and potential burns from continued heat transfer. Returning at a set interval ensures the device is removed before therapeutic warming shifts toward counterproductive hyperemia. A common error is assuming longer heat always improves healing; in sprains it can aggravate swelling if continued.

Question 12

A patient is being discharged from a skilled nursing facility. The patient has a history of severe COPD and PVD and is primarily concerned about breathing easily. Which of the following would be the best instruction for this patient?

Accepted Answer

Answer reason: Deep-breathing techniques, such as pursed-lip breathing, help reduce dyspnea by improving ventilation, preventing airway collapse, and enhancing oxygen exchange. This directly supports easier breathing in clients with severe COPD. Coughing after bronchodilator use helps with secretion clearance but does not primarily address the patient's concern of breathing more easily.

Question 13

Nurse Sullivan is educating Mr. Grant, a 60-year-old male client with chronic bronchitis, on breathing exercises to improve his respiratory function. Which technique should Nurse Sullivan emphasize in her teaching?

Accepted Answer

Answer reason: Chronic bronchitis (a COPD phenotype) often causes air trapping and inefficient ventilation, so teaching focuses on improving ventilatory mechanics and reducing work of breathing. Diaphragmatic breathing promotes better alveolar ventilation by using the diaphragm effectively, decreasing accessory muscle use and helping the client achieve deeper, more efficient breaths. In contrast, chest (upper-costal) breathing tends to increase fatigue and is less effective for ventilation in COPD. Prolonging inhalation over exhalation is counterproductive in obstructive disease because patients need a longer exhalation phase to limit air trapping.

Question 14

The nurse has given the male client with Bell's palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs additional information if the client states that he or she will?

Accepted Answer

Answer reason: Cold exposure can worsen discomfort and may exacerbate nerve irritation or muscle stiffness, so clients are typically advised to avoid drafts and cold temperatures. Gentle upward massage and targeted facial exercises help maintain muscle tone and stimulate facial muscles without causing strain. Specific movements like wrinkling the forehead, puffing cheeks, and whistling are standard facial exercises used to promote symmetric muscle activity during recovery.

Question 15

What is the best way to schedule medication for a client with constant pain?

Accepted Answer

Answer reason: This approach reduces pain peaks and valleys, improves function and sleep, and often lowers total breakthrough medication needs. PRN-only dosing commonly leads to delayed treatment and sensitization, making pain harder to control. Pre-procedure dosing is appropriate for predictable procedural pain but does not adequately address continuous baseline pain.

Question 16

What is the priority nursing concern for a client experiencing a migraine headache?

Accepted Answer

Answer reason: Nursing priority focuses on relieving suffering and restoring comfort using appropriate interventions (e.g., quiet/dark environment, minimizing stimuli, and timely analgesic/antimigraine therapy per orders). While anxiety can occur secondary to severe symptoms, it is not as physiologically urgent as uncontrolled pain in an uncomplicated migraine. Risk for brain injury is not a typical priority concern for a straightforward migraine absent red-flag neurologic findings suggesting an intracranial process.

Question 17

The nurse is about to change a dressing on an elderly man with Stage III pressure ulcer. What should be the nurse's first action?

Accepted Answer

Answer reason: Pain control should be addressed before performing potentially painful wound care to reduce physiologic stress, improve cooperation, and support effective healing. A stage III pressure injury dressing change and wound cleansing/debridement can cause significant discomfort, so verifying whether analgesia has been administered (and timing it appropriately) is the priority action before proceeding. Preparing supplies and donning gloves are important procedural steps but do not come before ensuring the patient is as comfortable as possible for the intervention. Explaining the procedure supports consent and cooperation, but unmanaged pain can still lead to intolerance and interrupted care.

Question 18

A postoperative client is prescribed IV patient-controlled analgesia (PCA) with morphine. The client tells the nurse, "I am pushing the button, but I'm still having a lot of pain." What is the priority nursing action?

Accepted Answer

Answer reason: Nursing actions should follow the assess-before-intervene principle, especially when current therapy appears ineffective. A comprehensive pain assessment (location, quality, intensity, timing, aggravating/relieving factors, sedation/respiratory status, and PCA history) helps determine whether the pain is expected postoperative pain, a complication, or inadequate analgesia. This also identifies issues such as pump malfunction, IV infiltration, dosing lockout limits, or opioid side effects that may be limiting use. Only after assessment should the nurse consider reinforcing PCA technique or contacting the provider for regimen changes. Administering an unscheduled bolus is unsafe and typically outside the nurse’s authority without an order and assessment of respiratory depression risk.

Question 19

A 75-year-old woman has been prescribed amitriptyline hydrochloride to manage neuropathic pain associated with diabetic neuropathy. She reports to the nurse that her pain level has decreased from a 7 to a 3 on a scale of 1–10. However, she is experiencing severe xerostomia. Which of the following strategies should the nurse choose to help relieve this symptom?

Accepted Answer

Answer reason: Amitriptyline is a tricyclic antidepressant with strong anticholinergic effects that reduce salivary gland secretion, causing dry mouth. Nonpharmacologic measures that stimulate saliva production are first-line for symptomatic relief, and sugar-free gum promotes salivation while limiting caries risk. Caffeine can worsen dehydration and dry mouth, while decreasing fluids would aggravate xerostomia. Increasing sodium would increase thirst and can be inappropriate in older adults due to potential cardiovascular and fluid-balance effects without directly improving salivation.

Question 20

The UAP tells you that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is reporting nasal passage discomfort. What intervention should you suggest to improve the patient’s comfort for this problem?

Accepted Answer

Answer reason: Oxygen delivered by nasal cannula at higher flow rates can dry and irritate the nasal mucosa, leading to burning, crusting, and discomfort. Adding humidification increases moisture content of the inspired gas and directly addresses the cause of mucosal dryness without changing the prescribed oxygen delivery method. Switching to a simple face mask is not primarily a comfort measure and may alter oxygen delivery and patient tolerance unnecessarily. Positioning changes or an extra pillow can help work of breathing, but they do not treat nasal passage irritation from dry oxygen flow.

Question 21

The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of tingling fingers and dizziness. Which action should the nurse take next?

Accepted Answer

Answer reason: Accelerated blow breathing can lead to hyperventilation, causing respiratory alkalosis and decreased ionized calcium, which presents as perioral/hand tingling and dizziness. The immediate nursing action is to increase the client’s CO2 level by rebreathing exhaled air, which helps relieve symptoms quickly and safely. Applying oxygen does not correct hypocapnia and may worsen the underlying problem by supporting continued overbreathing. Provider notification and additional assessments can follow if symptoms persist, but correcting the breathing pattern is the priority next step.

Question 22

A nurse is teaching a patient with COPD to perform pursed lip breathing. The nurse understands that the client needs further instruction when the patient states?

Accepted Answer

Answer reason: " Pursed-lip breathing is a nonpharmacologic technique that prolongs exhalation to create back-pressure (PEEP), helping prevent small-airway collapse in COPD. This reduces air trapping and can decrease dyspnea and anxiety by improving ventilation efficiency and giving the patient a sense of control. Teaching to exhale longer than inhale (often 1:2) reflects correct technique. Loosening or mobilizing secretions is not the primary purpose of pursed-lip breathing; airway clearance is better addressed with coughing techniques, hydration, humidification, and chest physiotherapy when indicated.

Question 23

A nursing diagnosis of "ineffective airway clearance related to pain" is identified for a client who had open abdominal surgery 2 days ago. Which intervention should the nurse implement first?

Accepted Answer

Answer reason: Treating pain first enables the client to participate effectively in pulmonary hygiene measures such as coughing, deep breathing, and incentive spirometry. Without analgesia, coaching incentive spirometry or coughing is less likely to be performed adequately due to guarding and discomfort. Splinting and fluids can support secretion mobilization, but they do not remove the primary barrier (pain) preventing effective airway clearance at this time.

Question 24

A child with an ankle sprain is being discharged from the emergency room. To promote tissue healing and relieve discomfort, the nurse instructs the parents to?

Accepted Answer

Answer reason: Acute soft-tissue injuries are managed initially with cold therapy to decrease local blood flow, limit edema, and reduce pain through decreased nerve conduction. Applying a cold compress in the first 24–48 hours helps control swelling and supports early tissue healing. Keeping the limb dependent increases venous pooling and worsens swelling and discomfort. Heat is generally avoided early because it promotes vasodilation and can increase edema and bleeding into tissues.

Question 25

A nurse working in the Post Anesthesia Care Unit (PACU) receives report on a 9-week old child that had a cleft lip repair. What nursing intervention is most important at preventing trauma to the surgical site?

Accepted Answer

Answer reason: Adequate pain control reduces agitation, crying, and self-soothing behaviors that increase hand-to-mouth movement and the risk of rubbing or pulling at the fresh lip incision. In a 9-week-old post-op infant, minimizing distress is a primary, preventive strategy to protect the surgical repair while maintaining airway and hemodynamic stability in PACU. A pacifier is typically contraindicated after cleft lip repair because sucking can place tension on the suture line and disrupt healing. Removing elbow restraints increases the likelihood the infant will touch the operative site, and repositioning alone does not address the core driver of incision trauma (pain/distress).

Question 26

Which of the following recommendations would be most helpful to suggest to a primigravid client at 37 weeks' gestation who has leg cramps?

Accepted Answer

Answer reason: Leg cramps in late pregnancy are commonly relieved by stretching the affected calf muscle to reduce spasm. Dorsiflexing the foot with the knee extended lengthens the gastrocnemius/soleus and helps abort an acute cramp quickly. Other general measures like changing positions or gentle flex/extend may help circulation but are less directly effective at stopping the cramp when it occurs. Prone positioning is not recommended in late third trimester due to discomfort and potential aortocaval compression issues with certain positions.

Question 27

As the nurse begins to assess the condition of a 9-year-old who is one day post appendectomy, the child cries out, “It hurts too much. I can’t do this.” What is the first action by the nurse?

Accepted Answer

Answer reason: Uncontrolled acute postoperative pain should be treated promptly to support effective participation in assessment, breathing/coughing, and early mobility, and to prevent physiologic stress responses. Treating pain first is an independent, immediate nursing action that improves cooperation and allows a more accurate evaluation afterward. Notifying the provider is not the first step when a standard postoperative analgesic plan is typically available and the patient is in distress. Threatening or shaming statements are nontherapeutic and can increase anxiety and pain perception, worsening outcomes.

Question 28

A nurse is assisting with the care of a newborn who is undergoing an IV insertion for dehydration. Which of the following clinical manifestations indicates the newborn is experiencing pain?

Accepted Answer

Answer reason: Sympathetic responses can include sweating, increased heart rate, increased blood pressure, and facial grimacing/crying during a painful procedure such as IV insertion. Sweating is therefore a physiologic indicator consistent with a pain/stress response. In contrast, increased vagal tone and decreased heart rate reflect parasympathetic dominance and are more consistent with vagal stimulation or physiologic instability rather than typical pain response. Pinpoint pupils suggest opioid effect or neurologic causes, not procedural pain.

Question 29

A client diagnosed with acquired immunodeficiency syndrome (AIDS) is being admitted to the hospital for treatment of a Pneumocystis jiroveci respiratory infection. Which intervention should the nurse include in the plan of care to assist in maintaining the comfort of this client?

Accepted Answer

Answer reason: Elevating the head of the bed improves lung expansion and ventilation, decreases diaphragmatic pressure, and often provides rapid symptomatic relief. The other choices are primarily assessment/monitoring activities aimed at detecting deterioration rather than directly improving comfort. Positioning is a safe, immediate, nonpharmacologic intervention that supports oxygenation while also enhancing perceived breathing comfort.

Question 30

A nurse teaches a client how to use a transcutaneous electrical nerve stimulator (TENS) device. Which statement by the client indicates a correct understanding of the teaching?

Accepted Answer

Answer reason: TENS therapy is a nonpharmacologic pain-management modality that must be used within prescribed parameters to optimize relief while minimizing adverse effects such as skin irritation, excessive stimulation discomfort, or unsafe use. Keeping the intensity at the ordered/prescribed level reflects correct adherence to the plan of care and safe device use teaching. The statement about not providing direct analgesia is incorrect because TENS is specifically used to reduce pain perception via neuromodulation. Routine shaving is not generally recommended due to risk of skin abrasion, and electrodes are often placed at/around the painful area per specific instructions rather than universally avoiding it.

Question 31

The unlicensed assistive personnel (UAP) tells the nurse that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is reporting nasal passage discomfort. What intervention should the nurse suggest to the UAP to improve the patient's comfort for this problem?

Accepted Answer

Answer reason: Drying of nasal mucosa from oxygen flow commonly causes irritation, burning, and epistaxis, so adding humidity addresses the direct mechanism of discomfort. At 6 L/min via nasal cannula, humidification is a standard comfort measure and can reduce mucosal dryness without compromising oxygen delivery. Switching to a simple mask changes the delivery device unnecessarily and may reduce comfort, communication, and oral intake while not targeting mucosal dryness as directly. Extra pillows or sitting in a chair may improve ventilation or dyspnea, but they do not specifically treat nasal passage irritation from dry oxygen.

Question 32

A nurse performs tracheostomy suctioning on a client with lower airway secretions. After several suctioning attempts, the nurse gets no secretions. The nurse assesses lung sounds and hears crackles. The nurse takes which action next?

Accepted Answer

Answer reason: If no secretions are obtained despite audible crackles, the catheter may be against the tracheal wall or inserted past the pooled secretions, so withdrawing slightly can restore patency and allow removal of secretions. Multiple unsuccessful passes increase risks (hypoxemia, dysrhythmias, mucosal injury), so adjusting position is the safest immediate corrective step before further attempts. Applying suction during insertion is unsafe because it can damage mucosa and worsen atelectasis. Offering oral fluids does not address lower-airway retained secretions in a tracheostomized client and delays airway clearance.

Question 33

The nurse is providing education for a client who has just been prescribed a transcutaneous electrical nerve stimulation (TENS) unit for relief of chronic back pain. Which of the following instructions to the client is correct?

Accepted Answer

Answer reason: " TENS is a nonpharmacologic pain modality that requires ongoing awareness of sensation and skin condition to prevent injury. Sleeping while it is running can reduce the client’s ability to perceive excessive stimulation, electrode displacement, or skin irritation/burns, increasing risk of harm. Therapeutic stimulation is typically described as a strong but comfortable tingling, not muscle twitching, which suggests intensity may be too high or electrodes poorly positioned. The duration and “tolerance building” are individualized by prescription and response, so fixed time claims are not reliable universal teaching points.

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