The responsibility of taking a 47-year-old female client's vital signs who was diagnosed with right breast cancer post-mastectomy has been assigned to the newly graduated nurse. Which of the following vital sign procedures should be considered?

Correct Answer: A

Rationale: Pulse oximeter on the left finger avoids the right mastectomy side, preventing lymphedema risk. Right finger and right arm BP are contraindicated. Left BP is okay but less specific here. Nurses, per NCLEX, protect surgical sides, making A correct.

Correct Answer: B

Rationale: Nonpharmacological interventions for pain focus on techniques that don't involve medications, aiming to enhance comfort through physical, psychological, or environmental means. Guided imagery, where patients visualize calming scenes to distract from pain, is a prime example, leveraging the mind-body connection to reduce pain perception. Choice A, administering morphine, is pharmacological, as it's a potent opioid drug used for severe pain. Choice C, prescribing ibuprofen, also falls under pharmacological methods, relying on an anti-inflammatory medication. Choice D, starting an IV opioid drip, is another drug-based approach, delivering opioids directly into the bloodstream. Choice B stands out as the correct nonpharmacological option, offering a holistic, medication-free way to manage pain, which nurses can implement alongside other therapies to improve patient comfort without the side effects or dependency risks associated with medications.

Correct Answer: B

Rationale: Symptom management is a key focus in end-of-life care, aiming to alleviate pain, nausea, dyspnea, or anxiety, ensuring the patient's final days are as comfortable as possible. This shifts priority from curing to caring, addressing physical and emotional suffering holistically. Choice A, aggressive curative measures, opposes this, as end-of-life care accepts the disease's terminality, avoiding futile treatments that may increase distress. Choice C, prolonged hospitalization, isn't a focuscare often moves to hospice or home settings for comfort and familiarity, not extended hospital stays. Choice D, avoiding patient interaction, is wrong; meaningful engagement with patients and families enhances dignity and support. Choice B stands out, reflecting palliative principles nurses uphold, using medications, positioning, or emotional care to manage symptoms, fostering peace over prolonging life unnecessarily.

Correct Answer: A

Rationale: The nurse most expects cool, clammy skin when assessing a client with acute pain, as it's a physiological response to sympathetic nervous system activationpain triggers stress, causing vasoconstriction and sweating, cooling the skin. This contrasts with chronic pain's subtler signs. Choice B, euphoria, is rareacute pain typically causes distress, not happiness, unless masked by strong analgesics, which isn't implied. Choice C, increased appetite, is unlikely; pain often suppresses hunger via stress hormones like cortisol. Choice D, lethargy, might occur in chronic pain from exhaustion, but acute pain usually heightens alertness initially due to adrenaline. Choice A is correct, reflecting a classic sign nurses assess in acute pain (e.g., post-injury), guiding interventions like analgesics or comfort measures to address both symptoms and underlying causes effectively.

Correct Answer: B

Rationale: The nurse would first try to determine why the client is refusing additional pain medication despite severe pain, as understanding the reasonfear of addiction, side effects, or cultural beliefsguides effective, respectful care. Post-surgical pain needs management, but forcing treatment violates autonomy. Choice A, forcing medication, is unethical and illegal, ignoring consent and escalating distress. Choice C, telling the client it's needed, assumes refusal stems from ignorance, not addressing underlying concerns, and may erode trust. Choice D, reporting to the surgeon, delays action; nurses assess first to inform reports with data. Choice B is correct, reflecting nursing's patient-centered approachasking open-ended questions (e.g., What worries you about the medication?') uncovers barriers, enabling education (e.g., on safety) or alternatives (e.g., non-opioids), ensuring pain relief aligns with the client's values and needs post-surgery.