a nurse is caring for a client who is in severe pain which of the following questions should the nurse ask first

ATI LPN

ATI PN Comprehensive Predictor

1. A nurse is caring for a client who is in severe pain. Which of the following questions should the nurse ask first?

A. How severe is your pain on a scale of 1 to 10?
B. Where is your pain located?
C. What medication are you taking for the pain?
D. When did the pain start?

Correct answer: B

Rationale: The correct answer is B: 'Where is your pain located?' When a client is experiencing severe pain, determining the location of the pain is crucial as it helps the nurse identify potential causes and select appropriate interventions. Option A may be important but assessing the location of pain takes precedence as it can provide valuable information for immediate management. Option C focuses on the current treatment, which is important but not the first priority. Option D, knowing when the pain started, is relevant but does not help in immediate pain management.

2. A nurse is preparing to administer purified protein derivative (PPD) to a client who has suspected tuberculosis. Which of the following actions should the nurse plan to take?

A. Ensure the injection produces a wheal on the skin
B. Administer the injection in the client's thigh
C. Use an intradermal needle for the injection
D. Avoid touching the site after injection

Correct answer: A

Rationale: The correct answer is A: Ensure the injection produces a wheal on the skin. A wheal indicates that the PPD has been administered correctly, allowing for the proper interpretation of results. Administering the injection in the client's thigh (choice B) is not the recommended site for PPD administration; it should be administered intradermally. Using an 18-gauge needle (choice C) is unnecessary and not the standard practice for PPD administration as a smaller gauge needle is preferred for intradermal injections. Massaging the site after injection (choice D) can lead to inaccurate results by dispersing the solution, so it is important to avoid touching the site after the injection to prevent altering the test results.

3. A client with asthma and a new prescription for an ipratropium inhaler is being taught by a nurse. Which statement by the client indicates an understanding of the teaching?

A. I will rinse my mouth after each use
B. I should wait 5 minutes before taking a second puff
C. I should take this medication when I wake up
D. I should wait 1 minute before taking a second puff

Correct answer: D

Rationale: The correct answer is D because waiting 1 minute between puffs ensures proper absorption of the medication. Choice A is incorrect as rinsing the mouth is not a specific instruction related to using the inhaler. Choice B is incorrect as waiting 5 minutes between puffs is longer than necessary. Choice C is incorrect as the timing of medication administration is not specified in the question.

4. How should a healthcare professional care for a patient with a colostomy?

A. Empty the colostomy bag regularly
B. Provide a high-fiber diet
C. Monitor for signs of infection
D. Change the colostomy bag every 3 days

Correct answer: A

Rationale: Emptying the colostomy bag regularly is essential to prevent leakage and infection. By regularly emptying the bag, the risk of irritation to the skin surrounding the stoma is reduced. Providing a high-fiber diet is important for overall bowel health but is not directly related to colostomy care. While monitoring for signs of infection is crucial, the primary focus should be on proper bag emptying. Changing the colostomy bag every 3 days may not be necessary for all patients and could vary based on individual needs and the type of colostomy.

5. What are common risk factors for urinary tract infections (UTIs)?

A. Poor hygiene and dehydration
B. Increased sexual activity and pregnancy
C. Use of urinary catheters and prolonged bed rest
D. Family history and obesity

Correct answer: A

Rationale: The correct answer is A: Poor hygiene and dehydration are common risk factors for urinary tract infections (UTIs). While choices B, C, and D may play a role in certain cases, poor hygiene and dehydration are more universally recognized as key factors contributing to UTIs. Increased sexual activity and pregnancy (choice B) can also increase the risk of UTIs, but they are not as universal as poor hygiene and dehydration. Choices C and D, the use of urinary catheters and prolonged bed rest, and family history and obesity, respectively, are risk factors for UTIs but are not as commonly associated as poor hygiene and dehydration.