the client had surgery one day ago what assessment is most likely related to pain the client had surgery one day ago what assessment is most likely related to pain
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Nursing Elites

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. The client had surgery one day ago. What assessment is most likely related to pain?

Correct answer: Blood pressure of 175/90 mm Hg

Rationale:

2. A teen with asthma asks the nurse why it is hard to breathe during an asthma attack. The nurse explains that exposure to a “trigger” results in which of these manifestations?

Correct answer: D

Rationale: The correct answer is D. Asthma triggers cause bronchoconstriction, airway inflammation, and increased mucus production, leading to difficulty breathing. This combination of manifestations results in narrowing of the airways, making it hard for the individual to breathe effectively. Choices A, B, and C are incorrect because during an asthma attack, bronchodilation, muscle relaxation, and decreased mucus production do not occur. Instead, the airways constrict, become inflamed, and produce excess mucus, contributing to the breathing difficulties experienced by individuals with asthma.

3. During examination of a toddler's extremities, the nurse notes that the child is bowlegged. The nurse should recognize that this finding is which?

Correct answer: D

Rationale: Bowleggedness is normal in toddlers due to the development of lower back and leg muscles. It usually resolves as the child grows.

4. The client on a beta blocker has a blood pressure of 88/58 mm Hg. What is the nurse’s priority action?

Correct answer: A

Rationale: The correct action for the nurse to take when a client on a beta blocker presents with a blood pressure of 88/58 mm Hg is to hold the beta blocker and notify the healthcare provider. Beta blockers can further decrease blood pressure, which is already low in this case. Administering the beta blocker as ordered (Choice B) would exacerbate the hypotension. Increasing the dose of the beta blocker (Choice C) would be inappropriate and unsafe given the low blood pressure. Continuing to monitor the client and reassessing in 30 minutes (Choice D) could lead to a delay in necessary intervention. Therefore, the priority is to hold the medication and seek guidance from the healthcare provider.

5. A client requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching?

Correct answer: C

Rationale: Option C demonstrates an understanding of the need to collect urine over 24 hours. The client's statement shows awareness that increased fluid intake will help in filling up the collection bottle quickly, which is essential for an accurate test result. This choice reflects the correct understanding of the teaching. Options A, B, and D do not reflect the necessary comprehension for a 24-hr urine collection process. Option A involves a bowel movement, which is not relevant to a urine collection. Option B only mentions a specimen from 30 minutes ago, not over a 24-hour period. Option D indicates flushing urine, which contradicts the idea of saving all urine for the test.

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