the nurse can promote relief of muscle pain spasms and tension by

NCLEX-PN

NCLEX-PN Quizlet 2023

1. How can the nurse promote relief of muscle pain, spasms, and tension?

A. Encouraging the client to continue their activities as usual.
B. Immobilizing the client.
C. Applying heat, cold, pressure, or vibration to the painful area.
D. Administering pain medication as needed to ease the muscle.

Correct answer: C

Rationale: To promote relief of muscle pain, spasms, and tension, the nurse should consider applying heat, cold, pressure, or vibration to the painful area. These interventions can help alleviate pain associated with muscle tension, pain, or spasms. Choice A is incorrect because encouraging the client to continue their activities as usual may exacerbate the pain. Choice B is incorrect as immobilizing the client may not address the underlying issue and could potentially lead to further complications. Choice D is also incorrect because while pain medication can be used, it is not the first-line treatment for muscle pain, spasms, and tension.

2. The nurse manager is having a problem on the unit with one staff person having repetitive tardiness and leaving the unit with orders not initiated. Which action by the manager would be best?

A. Call the staff nurse in and place them on a work improvement plan after a 3-day suspension
B. Have the other staff gather additional information on the tardy staff member
C. Call the staff nurse in for an interview to investigate the problem and possible solutions
D. Assign a mentor to assist the staff member in arriving on time

Correct answer: C

Rationale: The correct action for the nurse manager would be to call the staff nurse in for an interview to discuss the issues of repetitive tardiness and incomplete tasks. This approach allows the staff member to explain the situation, and together with the manager, develop a plan to address the problems. Choice A is incorrect as it immediately involves suspension without investigation or support. Choice B is not the best course of action as it does not involve direct communication with the staff member in question. Choice D, assigning a mentor to help the staff member, could be beneficial but does not directly address the immediate issues of tardiness and incomplete tasks.

3. The charge nurse is observing a student nurse caring for a 4-month-old infant in isolation diagnosed with RSV. Which of the following would indicate to the charge nurse that the student nurse needs further instruction on isolation standards?

A. Donning clean gloves each time she goes in the room.
B. Wearing a clean mask each time she goes in the room.
C. Labeling the door so staff will use Airborne Precautions.
D. Wearing a gown when she goes in the room to administer medication.

Correct answer: A

Rationale: The correct answer is 'Donning clean gloves each time she goes in the room.' Sterile gloves are not necessary for standard isolation precautions; clean gloves are sufficient. The student nurse should be instructed to use clean gloves to reduce the risk of spreading infections. Wearing a clean mask each time she goes in the room is a good practice to prevent the spread of respiratory infections like RSV. Labeling the door for Airborne Precautions is appropriate for RSV. Wearing a gown when entering the room to administer medication helps prevent the transmission of infectious agents.

4. A nurse is returning phone calls in a pediatric clinic. Which of the following reports most requires the nurse's immediate attention and phone call?

A. An 8-year-old boy has been vomiting, appears to have slower movements, and has a history of an atrioventricular shunt placement.
B. A 10-year-old girl feels a dull pain in her abdomen after doing sit-ups in gym class.
C. A 7-year-old boy has been having a low fever and headache for the past 3 days and has a history of an anterior knee wound.
D. A 7-year-old girl who had a cast on her right ankle is complaining of itching.

Correct answer: A

Rationale: The correct answer is the 8-year-old boy with vomiting, slower movements, and a history of an atrioventricular shunt placement. This report requires immediate attention because the symptoms could indicate a blocked shunt, which is a serious medical condition needing urgent evaluation and intervention. Slower movements in the context of an atrioventricular shunt history could suggest increased intracranial pressure. The other choices involve less urgent issues: choice B describes post-exercise pain, choice C presents with a low-grade fever and headache that could be due to a mild infection, and choice D reports itching associated with a cast, which is a common issue and less critical compared to a potentially blocked shunt.

5. Which task would be appropriate for the LPN to perform?

A. Changing a colostomy bag.
B. Hanging a new bag of TPN.
C. Drawing a peak antibiotic blood level from a central line.
D. Administering IV pain medication to a two-day post-op client.

Correct answer: A

Rationale: The correct answer is changing a colostomy bag. This task falls within the LPN's scope of practice. LPNs are trained to provide basic nursing care, including assisting with activities of daily living and certain medical procedures like changing ostomy bags. Hanging a new bag of TPN and drawing a peak antibiotic blood level from a central line are tasks that require a higher level of training and are typically performed by RNs due to their complexity and potential risks. Administering IV pain medication to a two-day post-op client is usually the responsibility of an RN as it involves close monitoring, assessment of the client's condition, and the administration of potent medications that require a higher level of clinical judgment and expertise.