the nurses assess the clients pain prior to completing a dressing change the client says his current pain is 510 but he has pain of 1010 when his dres

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. The nurses assess the client's pain prior to completing a dressing change. The client says his current pain is 5/10, but he has pain of 10/10 when his dressing is changed. What is the priority intervention for this client?

A. Offer the client protein with meals to promote healing
B. Remove the old dressing with clean gloves
C. Teach the client about nonpharmacological pain control methods
D. Check medication administration record (MAR)for as needed orders (PRN)

Correct answer: C

Rationale:

2. What is an example of a client's primary defense to infection?

A. Intact skin
B. Inflammation
C. Phagocytosis
D. Fever

Correct answer: A

Rationale:

3. The medical record for a client states that the client has hemiplegia. What does this mean?

A. The client can use his right arm, left leg, and left arm.
B. The client has paralysis of all four extremities.
C. The client has decreased vision in one eye.
D. The client has paralysis on one side of the body.

Correct answer: D

Rationale: Hemiplegia refers to paralysis on one side of the body, affecting either the right or left side. Choice A is incorrect because it describes selective paralysis of specific limbs, not one side of the body. Choice B is incorrect as hemiplegia does not involve paralysis of all four extremities. Choice C is also incorrect as decreased vision in one eye is not indicative of hemiplegia.

4. The nurse is caring for a client with rheumatoid arthritis one day after shoulder surgery. What would prompt the nurse to call the provider immediately?

A. The client refused her pain medication this morning and is doing physical therapy.
B. The client reports a minor headache and states she takes an over-the-counter pain pill at home.
C. The client reports intermittent flatus and minor abdominal discomfort.
D. The client has paresthesia in her fingers and intense increasing pain in her shoulder.

Correct answer: D

Rationale: In a client with rheumatoid arthritis one day after shoulder surgery, paresthesia in the fingers and intense increasing pain in the shoulder could indicate nerve compression or damage, which are serious post-operative complications. This situation requires immediate attention from the provider to prevent further complications and ensure appropriate management. The other options, such as refusing pain medication, reporting a minor headache, or experiencing minor abdominal discomfort, are important but not as urgent or indicative of potential serious complications as paresthesia in the fingers and intense increasing pain in the shoulder.