a client reports severe pain unrelieved by pain medication in a limb with traction what is the nurses priority
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN

1. A client reports severe pain unrelieved by pain medication in a limb with traction. What is the nurse's priority?

Correct answer: B

Rationale: The correct answer is B: Assess for compartment syndrome. Severe unrelieved pain in a limb with traction can be a sign of compartment syndrome, a surgical emergency. Prompt assessment is crucial to prevent potential complications. Increasing pain medication dosage without addressing the underlying cause may delay necessary interventions. Waiting for the healthcare provider may lead to a critical delay in treatment. Repositioning the client may not alleviate the pain if it is due to compartment syndrome, and it is crucial to assess for this condition first.

2. Which principle is most important for maintaining medical asepsis in a healthcare setting?

Correct answer: D

Rationale: The correct answer is D: Clean hands thoroughly before and after patient contact. Hand hygiene is crucial for maintaining medical asepsis in a healthcare setting as it helps prevent the spread of infections between patients and healthcare workers. Choice A is incorrect because instruments should be sterilized regularly, not just when visibly contaminated. Choice B is incorrect as sterile gloves are not required for all patient interactions, only for specific procedures. Choice C is incorrect because patient areas should be disinfected regularly throughout the day, not just at the end of the day.

3. What is the primary goal when caring for a patient with chronic obstructive pulmonary disease (COPD)?

Correct answer: A

Rationale: The correct answer is to maintain the patient's oxygen saturation above 90% when caring for a patient with COPD. In COPD, impaired gas exchange leads to decreased oxygen levels in the blood. By ensuring oxygen saturation remains above 90%, healthcare providers can prevent hypoxia and its complications. Administering bronchodilators as prescribed (Choice B) is an important intervention in managing COPD symptoms, but it is not the primary goal. Improving the patient's nutritional intake (Choice C) and encouraging the patient to limit physical activity (Choice D) are also essential aspects of COPD management, but they are not the primary goal when caring for a patient with this condition.

4. A nurse is preparing medications for a client via nasogastric tube. What should the nurse do before administering the medications?

Correct answer: B

Rationale: Before administering medications through a nasogastric tube, the nurse should administer them one after the other without flushing. Flushing the tube with water should be done before and after each medication to prevent any interactions and ensure each medication is delivered effectively. The correct answer is not to administer all medications at once (choice A) as this can lead to potential drug interactions. Crushing all medications and mixing them together (choice C) is incorrect as each medication should be given separately to maintain their individual efficacy. Administering medications in liquid form only (choice D) is limiting and may not be suitable for all types of medications that need to be administered.

5. A nurse is providing discharge instructions to a client who has a new prescription for codeine for cough suppression. What is the priority instruction?

Correct answer: C

Rationale: The correct answer is to instruct the client to 'Move slowly when standing up.' Codeine can cause orthostatic hypotension, a drop in blood pressure when changing positions, leading to dizziness or fainting. By advising the client to move slowly when standing up, the nurse helps prevent falls or injuries due to sudden drops in blood pressure. Choices A, B, and D are important instructions as well but not the priority when considering the risk of orthostatic hypotension associated with codeine.

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