a patient is receiving an opioid analgesic for pain management what is the most important assessment for the nurse to perform
Logo

Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment A

1. A patient is receiving an opioid analgesic for pain management. What is the most important assessment for the nurse to perform?

Correct answer: B

Rationale: The correct answer is to assess the patient's respiratory rate. When a patient is receiving opioids, it is crucial to monitor their respiratory rate as opioids can depress the respiratory system, leading to respiratory depression and potential respiratory failure. Monitoring blood pressure, oxygen saturation, and heart rate are important assessments as well, but the priority lies in assessing respiratory rate due to the risk of respiratory depression associated with opioid use.

2. A nurse notices another nurse skipping hand hygiene. What is the appropriate course of action?

Correct answer: B

Rationale: Correct hand hygiene is crucial for preventing the spread of infections and ensuring patient safety. When a nurse observes another healthcare worker skipping hand hygiene practices, it is essential to report this behavior to the supervisor. Reporting ensures that appropriate action is taken to address the issue and maintain a safe environment for patients. Ignoring the situation (Choice A) may compromise patient safety. Discussing the issue directly with the nurse (Choice C) may not always be effective in ensuring compliance. Doing nothing and continuing with patient care (Choice D) disregards the importance of infection control protocols.

3. Which nursing action is essential when administering a blood transfusion?

Correct answer: C

Rationale: The correct answer is to administer the transfusion at a slow rate for the first 15 minutes. This practice is crucial as it helps in detecting any adverse reactions early on. Checking the patient's vital signs every 30 minutes (choice B) is important but not as essential as ensuring a slow rate at the beginning. Administering blood within 4 hours (choice A) is a standard practice but not directly related to the initial administration. Documenting the transfusion immediately (choice D) is necessary but does not directly impact the safety of the initial administration.

4. What is the most appropriate method for preventing catheter-associated urinary tract infections (CAUTIs)?

Correct answer: B

Rationale: The correct answer is B: Limit the duration of catheter use. Limiting the duration of catheterization is a crucial method for preventing catheter-associated urinary tract infections (CAUTIs). Prolonged catheter use increases the risk of introducing pathogens into the urinary tract, leading to infections. Using clean gloves for insertion (choice A) is important for preventing contamination but does not address the main cause of CAUTIs. Using a smaller size catheter (choice C) may help reduce trauma but does not directly prevent infections. Changing the catheter tubing every 24 hours (choice D) is not necessary unless clinically indicated, and it is not the most effective method for preventing CAUTIs.

5. A nurse is preparing to administer digoxin 0.25 mg PO daily. The amount available is digoxin 0.125 mg tablets. How many tablets should the nurse administer?

Correct answer: B

Rationale: The correct answer is B: 2. To achieve the prescribed dose of 0.25 mg of digoxin, the nurse should administer two 0.125 mg tablets. This calculation ensures that the patient receives the correct amount of medication. Choices A, C, and D are incorrect because they do not reflect the accurate dosage needed based on the available tablets and prescribed dose.

Similar Questions

The patient experienced a surgical procedure, and Betadine was utilized as the surgical prep. Two days postoperatively, the nurse's assessment indicates that the incision is red and has a small amount of purulent drainage. The patient reports tenderness at the incision site. The patient's temperature is 100.5°F, and the WBC is 10,500/mm³. Which action should the nurse take first?
A healthcare professional is reviewing the notes written by a previous shift. Which documentation reflects proper guidelines?
What intervention should the nurse implement for a patient receiving a blood transfusion?
The nurse is assessing the patient for respiratory complications of immobility. What action should the nurse take?
A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses