where will the nurse collect the most reliable source of pain assessment
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Nursing Elites

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. Where will the nurse collect the most reliable source of pain assessment?

Correct answer: C

Rationale:

2. A client who is sitting in High-Fowler's position is at risk for what type of injury as the skin layers shift in opposite directions?

Correct answer: D

Rationale:

3. The nurse is caring for a client with rheumatoid arthritis one day after shoulder surgery. What would prompt the nurse to call the provider immediately?

Correct answer: D

Rationale: In a client with rheumatoid arthritis one day after shoulder surgery, paresthesia in the fingers and intense increasing pain in the shoulder could indicate nerve compression or damage, which are serious post-operative complications. This situation requires immediate attention from the provider to prevent further complications and ensure appropriate management. The other options, such as refusing pain medication, reporting a minor headache, or experiencing minor abdominal discomfort, are important but not as urgent or indicative of potential serious complications as paresthesia in the fingers and intense increasing pain in the shoulder.

4. What intervention by the nurse would be the best to prevent deep vein thrombosis after a fracture of the hip?

Correct answer: B

Rationale: The best intervention to prevent deep vein thrombosis (DVT) after a fracture of the hip is to apply antiembolism stockings. These stockings help promote circulation and prevent blood clots from forming in the legs due to immobility. Encouraging bedrest is not recommended as it can increase the risk of DVT. While anticoagulants are used in some cases, the primary prevention method is mechanical prophylaxis like antiembolism stockings. Teaching about smoking cessation is important for overall health but is not directly related to preventing DVT in this scenario.

5. The goal for a client with impaired mobility is to prevent atelectasis. What nursing intervention would best help the client meet this goal?

Correct answer: A

Rationale: Assisting the client to the orthopneic position is the best nursing intervention to help prevent atelectasis. This position improves lung expansion by allowing the chest to expand fully, aiding in the prevention of atelectasis. Offering a protein-rich diet (choice B) is important for overall nutrition but does not directly address preventing atelectasis. Offering a bedpan for toileting (choice C) and turning the client every 4 hours (choice D) are important for preventing pressure ulcers in immobile clients but do not directly prevent atelectasis.

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