how should a nurse assess pain in a non verbal patient

ATI RN

ATI RN Exit Exam 2023

1. How should pain be assessed in a non-verbal patient?

A. Observe facial expressions
B. Use the Wong-Baker faces scale
C. Assess heart rate
D. Ask the patient to rate their pain

Correct answer: A

Rationale: Observing facial expressions is essential in assessing pain levels in non-verbal patients. Non-verbal cues, such as facial grimacing, furrowed brows, or clenched jaws, can provide valuable information about the patient's pain experience. Using the Wong-Baker faces scale or assessing heart rate may not be as effective in non-verbal patients as they are unable to communicate their pain through these methods. Asking the patient to rate their pain is also not suitable for non-verbal patients as they may not have the ability to verbally communicate their pain levels.

2. A client with a new diagnosis of type 1 diabetes mellitus is being taught by a nurse about insulin administration. Which of the following instructions should the nurse include?

A. Store unopened vials of insulin in the refrigerator, not the freezer.
B. Rotate injection sites within the same region to prevent tissue damage.
C. Administer insulin at a 90-degree angle for subcutaneous injections.
D. Avoid massaging the injection site after administering insulin.

Correct answer: B

Rationale: The correct answer is to rotate injection sites within the same region to prevent tissue damage. By rotating sites, the client can prevent lipodystrophy, which is a condition characterized by the loss or change in body fat at the site of repeated injections. This practice also helps to ensure proper insulin absorption. Storing unopened vials of insulin in the refrigerator (Choice A) is correct, not in the freezer, as freezing can damage the insulin. Administering insulin at a 90-degree angle (Choice C) is more appropriate for subcutaneous injections, while a 45-degree angle is used for intramuscular injections. Massaging the injection site after administering insulin (Choice D) is not recommended as it can affect insulin absorption rates.

3. What is the best position for a patient with respiratory distress?

A. Semi-Fowler's position
B. Trendelenburg position
C. Prone position
D. Supine position

Correct answer: A

Rationale: The best position for a patient with respiratory distress is the Semi-Fowler's position. This position promotes lung expansion and improves oxygenation by allowing the chest to expand more fully. The Trendelenburg position, where the patient's feet are higher than the head, is contraindicated in respiratory distress as it can increase pressure on the diaphragm and compromise breathing. The prone position, lying face down, may be beneficial in certain cases like acute respiratory distress syndrome but is not generally recommended for all patients in respiratory distress. The supine position, lying flat on the back, can worsen respiratory distress by causing the tongue to fall back and obstruct the airway.

4. A nurse is caring for a client who is 24 hours postpartum and is breastfeeding her newborn. The client asks the nurse to warm up seaweed soup that her partner brought for her. Which of the following responses should the nurse make?

A. Does the doctor know you are eating that?
B. Why are you eating seaweed soup?
C. Of course, I will heat that up for you.
D. The hospital food is more nutritious.

Correct answer: C

Rationale: Respecting cultural preferences promotes trust and client-centered care.

5. A client has a central venous catheter. Which of the following actions should be taken to prevent an air embolism?

A. Keep the catheter clamped when not in use
B. Have the client perform the Valsalva maneuver while the catheter is removed
C. Use a non-coring needle to access the catheter
D. Flush the catheter with 0.9% sodium chloride every 24 hours

Correct answer: B

Rationale: The correct action to prevent an air embolism in a client with a central venous catheter is to have the client perform the Valsalva maneuver while the catheter is removed. This maneuver helps to close the airway and prevent air from entering the bloodstream. Keeping the catheter clamped at all times (Choice A) is not necessary and may lead to clot formation. Using a non-coring needle (Choice C) is important for accessing the catheter but does not specifically prevent air embolism. Flushing the catheter with 0.9% sodium chloride (Choice D) helps maintain patency but does not directly prevent air embolism.