Term III Clinical Quiz 3

A nurse is assessing pain on a confused older client who has difficulty with verbal expression. What pain assessment tool would the nurse choose for this assessment?

• Numeric rating scale

• Verbal Descriptor Scale

• FACES Pain Scale-Revised

• Wong-Baker FACES Pain Scale

A client is undergoing computed tomography (CT) of a joint. What action by the nurse is most important before the test?

• Administer sedation as prescribed.

• Assess for seafood or iodine allergy.

• Ensure that the client has no metal on the body.

• Provide pre-procedure pain medication.

A client has been advised to perform weight-bearing exercises to help minimize osteoporosis. The client admits to not doing the prescribed exercises. What action by the nurse is best?

• Ask the client about fear of falling.

• Instruct the client to increase calcium.

• Suggest other exercises the client can do.

• Tell the client to try weight lifting.

The nurse sees several clients with osteoporosis. For which client would bisphosphonates not be a good option?

• Client with diabetes who has a serum creatinine of 0.8 mg/dL

• Client who recently fell and has vertebral compression fractures

• Hypertensive client who takes calcium channel blockers

• Client with a spinal cord injury who cannot tolerate sitting up

A client has been prescribed denosumab (Prolia). What instruction about this drug is most appropriate?

• "Drink at least 8 ounces of water with it."

• "Make appointments to come get your shot."

• "Sit upright for 30 to 60 minutes after taking it."

• "Take the drug on an empty stomach."

A nurse sees clients in an osteoporosis clinic. Which client should the nurse see first?

• Client taking calcium with vitamin D (Os-Cal) who reports flank pain 2 weeks ago

• Client taking ibandronate (Boniva) who cannot remember when the last dose was

• Client taking raloxifene (Evista) who reports unilateral calf swelling

• Client taking risedronate (Actonel) who reports occasional dyspepsia

A client with osteoporosis is going home, where the client lives alone. What action by the nurse is best?

• Arrange a home safety evaluation.

• Ensure the client has a walker at home.

• Help the client look into assisted living.

• Refer the client to Meals on Wheels.

Alan, RN assesses a client with a fracture who is being treated with skeletal traction. Which assessment should alert the nurse to urgently contact the health provider?

• Blood pressure increases to 130/86 mm Hg

• Traction weights are resting on the floor

• Oozing of clear fluid is noted at the pin site

• Capillary refill is less than 3 seconds

Kathy, RN assesses an older adult client who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless. The client’s vital signs are heart rate 98 beats/min, respiratory rate 32 breaths/min, blood pressure 132/78 mm Hg, and SpO₂ 88%. Which action should the nurse take first?

• Administer oxygen via nasal cannula.

• Re-position to a high-Fowler’s position.

• Increase the intravenous flow rate.

• Assess response to pain medications

A nurse is educating a 21-year-old lifeguard about the risk of skin cancer and the need to wear sunscreen. Which statement by the patient indicates that they need further teaching?

• "I wear a hat and sit under the umbrella when not in the water."

• "I don't bother with sunscreen on overcast days."

• "I use a sunscreen with the highest SPF number."

• "I wear a UV shirt and limit exposure to the sun by covering up."