what are the key components of a pain assessment in a postoperative patient

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B

1. What are the key components of a pain assessment in a postoperative patient?

A. Checking the effectiveness of pain interventions
B. Observing for nonverbal signs of pain like grimacing
C. Assessing the location, duration, and quality of the pain
D. Asking the patient to rate their pain on a scale of 1-10

Correct answer: A

Rationale: The correct answer is A because in a postoperative patient, it is crucial to evaluate the effectiveness of the pain interventions that have been implemented. While choices B, C, and D are important aspects of a pain assessment, they do not specifically address the key component of assessing the effectiveness of the interventions applied postoperatively.

2. Which intervention reduces reservoirs of infection in a healthcare setting?

A. Placing capped needles and syringes in puncture-resistant containers
B. Keeping bedside table surfaces clean and dry
C. Changing dressings that become wet or soiled
D. Placing tissues and soiled dressings in paper bags

Correct answer: A

Rationale: Placing capped needles and syringes in puncture-resistant containers is the correct intervention to reduce infection reservoirs in healthcare settings. This practice helps prevent accidental needle-stick injuries and contains potentially infectious materials properly. Keeping bedside table surfaces clean and dry (choice B) is essential for preventing the spread of infections but does not directly address reducing reservoirs of infection. Changing dressings that become wet or soiled (choice C) is important for wound care but does not specifically target infection reservoirs. Placing tissues and soiled dressings in paper bags (choice D) is a proper waste disposal practice but does not directly reduce reservoirs of infection in a healthcare setting.

3. When providing discharge instructions for a patient with diabetes, what is the most important information to include?

A. Encourage the patient to maintain a high-carbohydrate diet.
B. Teach the patient how to monitor their blood sugar levels.
C. Recommend the patient engage in regular exercise.
D. Provide the patient with a list of restricted foods.

Correct answer: B

Rationale: The most critical information to include when providing discharge instructions for a patient with diabetes is teaching them how to monitor their blood sugar levels. This empowers the patient to actively manage their condition, make informed decisions about their diet and medication, and prevent complications. Encouraging a high-carbohydrate diet (Choice A) can be detrimental for diabetic patients as it may lead to unstable blood sugar levels. While regular exercise (Choice C) is important in diabetes management, monitoring blood sugar levels takes precedence. Providing a list of restricted foods (Choice D) is relevant but not as crucial as teaching the patient how to monitor their blood sugar levels.

4. A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first?

A. Measure and document the urine in the drainage bag
B. Remove the tape or device securing the catheter to the client's thigh
C. Position the client supine
D. Deflate the catheter balloon using a sterile syringe

Correct answer: A

Rationale: The correct first action the nurse should take when discontinuing a client's indwelling urinary catheter is to measure and document the urine in the drainage bag. This step is essential to assess the client's urinary output and bladder function before removing the catheter. Removing the tape securing the catheter (Choice B) or positioning the client supine (Choice C) should come after measuring and documenting the urine output. Deflating the catheter balloon (Choice D) is the last step in the process of removing the catheter.

5. A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which of the following actions should the nurse take? (SATA)

A. Change the client's position
B. Identify the client's pain level
C. Remind the client to use incisional splinting
D. Offer the client a back rub

Correct answer: A

Rationale: The correct actions the nurse should take when caring for a client postoperative following a cholecystectomy and reporting pain include changing the client's position. This can help relieve postoperative pain by reducing pressure on the surgical site. Identifying the client's pain level is important but not specific to alleviating postoperative pain. While reminding the client to use incisional splinting can be beneficial, it may not directly address the immediate pain concern. Offering the client a back rub is not typically indicated for postoperative pain relief after a cholecystectomy.