a nurse is caring for a client who is receiving an opioid analgesic for pain management which of the following assessments is the nurses priority
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Nursing Elites

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ATI RN Exit Exam Test Bank

1. While caring for a client receiving an opioid analgesic for pain management, which assessment should the nurse prioritize?

Correct answer: D

Rationale: The correct answer is to monitor the client's respiratory rate. When a client is receiving opioids, the priority assessment is the respiratory rate since opioids can lead to respiratory depression. Monitoring urinary output, blood pressure, and constipation are also important but not the priority in this scenario.

2. A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. Which of the following group facilitation techniques should the nurse include in the teaching?

Correct answer: D

Rationale: The correct answer is D: 'Use modeling to help the clients improve their interpersonal skills.' Modeling is an effective therapeutic technique where the leader demonstrates appropriate behaviors for the group to learn from. This technique can help clients improve their interpersonal skills by observing and replicating positive behaviors. Choices A, B, and C are incorrect. Sharing personal opinions to influence the group's values may not be appropriate as it could hinder the group dynamics and individual autonomy. Comparing accomplishments against a previous group is not a recommended technique as each group is unique, and comparisons may not be beneficial. Yielding in conflicts to maintain group harmony may lead to unresolved issues and hinder the group's progress.

3. A nurse is caring for a client who is postoperative following a craniotomy. Which of the following findings indicates the client is developing diabetes insipidus?

Correct answer: A

Rationale: Polyuria is the correct finding indicating the client is developing diabetes insipidus. Diabetes insipidus is characterized by the excretion of large volumes of diluted urine due to a deficiency in antidiuretic hormone. This results in increased urine output (polyuria) despite adequate fluid intake. Hypertension (choice B) is not typically associated with diabetes insipidus but can be seen in other conditions. Bradycardia (choice C) and hyperglycemia (choice D) are also not typical findings of diabetes insipidus.

4. What is the priority nursing intervention for a patient experiencing an acute asthma attack?

Correct answer: A

Rationale: The correct answer is to administer bronchodilators as the priority nursing intervention for a patient with an acute asthma attack. Bronchodilators help open the airways and improve airflow, which is crucial in managing acute asthma symptoms. Administering corticosteroids (Choice B) is also important in the treatment plan, but it is not the priority intervention during an acute attack. Providing supplemental oxygen (Choice C) may be necessary but is not the priority initial intervention. Starting IV fluids (Choice D) is not typically indicated as a priority intervention for an acute asthma attack.

5. A client is receiving chemotherapy and is being taught about preventing infection. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: Clients receiving chemotherapy are instructed to avoid fresh fruits and vegetables to lower the risk of infection. Fresh produce may harbor bacteria or other pathogens that could be harmful to individuals with compromised immune systems. Taking the temperature daily may be important but is not directly related to preventing infection. Limiting high-protein foods is not necessary unless there are specific dietary restrictions due to the treatment plan. Increasing the intake of high-fat foods is not recommended during chemotherapy as a high-fat diet may lead to other health issues.

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