the nurse is evaluating the effectiveness of guided imagery for pain management as used for a patient who has second and third degree burns and needs
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN

1. The nurse is evaluating the effectiveness of guided imagery for pain management in a patient with second- and third-degree burns requiring extensive dressing changes. Which finding best indicates the effectiveness of guided imagery?

Correct answer: A

Rationale: The correct answer is A. A reduction in the need for analgesic medication indicates that guided imagery is effective in managing the patient's pain. Choices B, C, and D do not directly measure the effectiveness of guided imagery. A patient rating pain as 6 on a scale of 0 to 10, asking for pain medication once, or having stoic facial expressions may not necessarily reflect the impact of guided imagery on pain management.

2. A nurse is providing discharge instructions to a client following a gastrectomy. Which of the following strategies should the nurse include in the teaching?

Correct answer: D

Rationale: The correct strategy to include in the teaching after a gastrectomy is to avoid drinking liquids with meals. This helps prevent dumping syndrome, a condition characterized by rapid emptying of undigested food and fluids from the stomach into the small intestine. Choices A, B, and C are incorrect. Drinking fluids between meals is appropriate to maintain hydration, eating three large meals can exacerbate dumping syndrome, and lying down after meals is not recommended as it can increase the risk of reflux.

3. A nurse is assessing the skin of an immobilized patient. What will the nurse do?

Correct answer: A

Rationale: The correct answer is A. When assessing the skin of an immobilized patient, it is essential to use a standardized tool such as the Braden Scale to identify patients at high risk for impaired skin integrity. This tool helps in early identification and appropriate intervention. Choice B, limiting fluid intake, is not directly related to skin assessment. Choice C, having special times for inspection, may not ensure timely identification of skin issues. Choice D, assessing the skin every 4 hours, lacks specificity regarding the use of a validated tool for risk assessment.

4. A nurse suspects a colleague of diverting narcotics. What is the nurse's first course of action?

Correct answer: B

Rationale: The correct first course of action for a nurse suspecting a colleague of diverting narcotics is to report the suspicion to the nurse manager. Confronting the colleague directly may not be safe and could compromise the investigation. Ignoring the situation is not appropriate as it can pose risks to patient safety. Keeping a record of the colleague's actions is not the primary action to take when drug diversion is suspected; reporting to the nurse manager is crucial for proper investigation and ensuring patient safety.

5. What is the priority intervention for a patient experiencing chest pain?

Correct answer: A

Rationale: The correct answer is to administer nitroglycerin as prescribed. Nitroglycerin helps relieve chest pain by dilating blood vessels and improving blood flow, addressing the immediate concern of chest pain. Encouraging deep breaths may not be appropriate for chest pain, monitoring blood pressure, although important, is not the priority when the patient is experiencing chest pain, and while resting in a comfortable position is beneficial, administering nitroglycerin is the priority intervention to address the chest pain.

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