a patient is experiencing pain after surgery what is the nurses priority action a patient is experiencing pain after surgery what is the nurses priority action
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment A

1. After surgery, a patient is experiencing pain. What is the nurse's priority action?

Correct answer: B

Rationale: The correct answer is to assess the patient's pain using a pain scale. This is the priority action because it allows the nurse to obtain an objective measure of the patient's pain intensity. By accurately assessing the pain level, the nurse can determine the appropriate intervention, which may include administering pain medication as prescribed (choice A) or offering non-pharmacological pain relief methods (choice C). Reassessing the patient's pain level after 30 minutes (choice D) is important but comes after the initial assessment to evaluate the effectiveness of the interventions implemented.

2. A client is being instructed by a nurse about foods that should be included in a low-fiber diet. Which statement by the client indicates understanding?

Correct answer: D

Rationale: The correct answer is D because canned peaches are lower in fiber compared to the other options. Carrots, celery sticks, bran muffins, and oatmeal are high-fiber choices, which are not suitable for a low-fiber diet. Choosing canned peaches aligns with the requirements of a low-fiber diet.

3. What is a chronic condition where the heart is unable to pump blood effectively, leading to fluid buildup in the lungs and other parts of the body?

Correct answer: A

Rationale: The correct answer is A: Heart failure. Heart failure is a chronic condition characterized by the heart's inability to pump blood effectively, resulting in fluid accumulation in the lungs and other body tissues. Myocardial infarction (choice B) refers to a heart attack caused by a blocked coronary artery, leading to damage of heart muscle tissue. Pericarditis (choice C) is the inflammation of the pericardium, the protective sac around the heart. Pulmonary edema (choice D) is a condition where fluid builds up in the lungs, often as a result of heart failure.

4. A client with neuropathic pain has a new prescription for amitriptyline once per day. What should the nurse include in the teaching?

Correct answer: B

Rationale: The correct answer is B: 'Increase fluids while on this medication.' Amitriptyline can cause side effects like dry mouth and urinary retention. Increasing fluids can help alleviate these side effects. Choices A, C, and D are incorrect. Taking the medication with meals or only at night is not specifically related to managing the side effects of amitriptyline. Reporting yellowing of the skin is important but not directly related to the side effects of this medication.

5. A nurse is caring for a client who has a new prescription for metformin. Which of the following instructions should the nurse include?

Correct answer: C

Rationale: The correct instruction for a client prescribed metformin is to take the medication with meals to improve absorption and reduce gastrointestinal upset. Metformin is typically recommended to be taken with food to minimize side effects. Option A is incorrect as taking metformin on an empty stomach may increase the risk of gastrointestinal side effects. Option B is unrelated as metformin does not interact with potassium-rich foods. Option D is also incorrect as metformin does not cause drowsiness, so there is no need to take it before bed.

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