how should a nurse assess a patients pain level post surgery

ATI RN

ATI RN Exit Exam 2023

1. How should a healthcare professional assess a patient's pain level post-surgery?

A. Use a pain rating scale
B. Check vital signs
C. Observe for non-verbal cues
D. Check for abnormal breath sounds

Correct answer: A

Rationale: Corrected Rationale: Using a pain rating scale is the most appropriate method to assess a patient's pain level post-surgery. Pain rating scales provide a standardized way for patients to communicate their pain intensity, allowing for accurate assessment and effective pain management. Checking vital signs (choice B) is important for monitoring a patient's overall health status but may not directly reflect their pain level. Observing for non-verbal cues (choice C) is valuable, but it may not always provide a clear indication of the pain intensity. Checking for abnormal breath sounds (choice D) is relevant for assessing respiratory status but does not directly evaluate the patient's pain level.

2. A healthcare professional is preparing to administer an intermittent enteral feeding to a client who has a nasogastric tube. Which of the following actions should the healthcare professional take first?

A. Check the residual volume before administering the feeding
B. Elevate the head of the bed to 30 degrees
C. Flush the tube with 10 mL of sterile water
D. Verify the client's tube placement

Correct answer: D

Rationale: Verifying the client's tube placement is the priority before administering any enteral feeding. This step ensures that the tube is correctly positioned in the stomach or intestines, minimizing the risk of complications such as aspiration. Checking the residual volume, elevating the head of the bed, and flushing the tube are important steps but should occur after confirming the tube placement to ensure the feeding is delivered safely and effectively.

3. How should fluid balance be assessed in a patient receiving diuretics?

A. Monitor daily weight
B. Monitor intake and output
C. Check for edema
D. Monitor blood pressure

Correct answer: A

Rationale: Corrected Rationale: Monitoring daily weight is the most accurate method to assess fluid balance in patients receiving diuretics. Changes in weight reflect changes in fluid balance, making it a sensitive indicator. Monitoring intake and output (choice B) is important but may not provide a complete picture of overall fluid balance. Checking for edema (choice C) is a late sign of fluid imbalance and may not be sensitive enough to detect subtle changes. Monitoring blood pressure (choice D) is relevant but may not directly reflect fluid balance as it can be influenced by various other factors.

4. What should be monitored when administering opioids to a patient?

A. Monitor blood pressure
B. Monitor respiratory rate
C. Monitor heart rate
D. Monitor oxygen saturation

Correct answer: B

Rationale: When administering opioids, monitoring the respiratory rate is crucial to detect any signs of respiratory depression, which is a serious side effect of opioid use. Monitoring blood pressure, heart rate, and oxygen saturation are important parameters to assess a patient's overall condition, but they are not the primary focus when administering opioids.

5. A nurse is assessing a client who is 2 days postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

A. Serosanguineous drainage on the dressing
B. Heart rate of 88/min
C. Urine output of 30 mL/hr
D. Blood pressure of 110/70 mm Hg

Correct answer: C

Rationale: The correct answer is C because a urine output of 30 mL/hr indicates oliguria, which can be a sign of dehydration or kidney impairment postoperatively. This finding should be reported to the provider for further evaluation. Choices A, B, and D are within normal parameters for a client who is 2 days postoperative following abdominal surgery and do not raise immediate concerns. Serosanguineous drainage on the dressing is an expected finding in the early postoperative period, a heart rate of 88/min is within the normal range, and a blood pressure of 110/70 mm Hg is also within normal limits.