a patient is receiving an opioid analgesic for pain management what is the most important assessment for the nurse to perform
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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. Which personality disorder is characterized by disregard for others and manipulative behaviors?

Correct answer: B

Rationale: Antisocial Personality Disorder is the correct answer. This disorder is characterized by a pervasive pattern of disregard for and violation of the rights of others. Individuals with this disorder often display behaviors such as manipulation, exploitation, and a lack of empathy. Choice A, Borderline Personality Disorder, is characterized by unstable moods, behavior, and relationships. Choice C, Histrionic Personality Disorder, is characterized by attention-seeking behavior and excessive emotions. Choice D, Narcissistic Personality Disorder, is characterized by a grandiose sense of self-importance, a need for admiration, and a lack of empathy for others.

3. What is the primary focus of secondary prevention in community mental health care?

Correct answer: B

Rationale: The correct answer is B: Early detection of mental illness. Secondary prevention in community mental health care focuses on identifying mental health issues at an early stage to provide timely interventions. Choice A, teaching stress-reduction techniques, is more aligned with primary prevention aimed at preventing the onset of mental health problems. Choice C, leading support groups for clients with substance use disorder, pertains more to providing specific interventions for individuals with substance use issues rather than the general focus of secondary prevention. Choice D, rehabilitation and prevention of further issues, is more related to tertiary prevention, which involves addressing existing mental health conditions and preventing complications or recurrence.

4. A patient requires repositioning every 2 hours. Which task can the nurse delegate to the nursing assistive personnel?

Correct answer: B

Rationale: The correct answer is B: 'Changing the patient's position.' Repositioning the patient every 2 hours can be delegated to nursing assistive personnel as it involves physically moving the patient. Tasks like determining the level of comfort (choice A) and assessing circulation (choice D) are clinical judgments that require a nursing license and should be performed by the nurse. Similarly, identifying immobility hazards (choice C) involves critical thinking and assessment skills that are within the nurse's scope of practice.

5. A nurse is discussing organ donation with a newly licensed nurse. Which of the following statements should the nurse include in the teaching?

Correct answer: C

Rationale: The correct answer is C. Asking clients over 18 about their organ donation status upon admission is essential to ensure their wishes are respected. Option A is incorrect because organ donation requires consent, not harvesting. Option B is incorrect because the transplant team, not the donor client's provider, is responsible for organ retrieval. Option D is incorrect because the National Organ Transplant Act prohibits the commercialization of organ transactions, not their donation.

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