what are the key components of a pain assessment in a postoperative patient

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B

1. What are the key components of a pain assessment in a postoperative patient?

A. Checking the effectiveness of pain interventions
B. Observing for nonverbal signs of pain like grimacing
C. Assessing the location, duration, and quality of the pain
D. Asking the patient to rate their pain on a scale of 1-10

Correct answer: A

Rationale: The correct answer is A because in a postoperative patient, it is crucial to evaluate the effectiveness of the pain interventions that have been implemented. While choices B, C, and D are important aspects of a pain assessment, they do not specifically address the key component of assessing the effectiveness of the interventions applied postoperatively.

2. Which nursing action is essential when administering a blood transfusion?

A. Ensure the blood is administered within 4 hours.
B. Check the patient's vital signs every 30 minutes during the transfusion.
C. Administer the transfusion at a slow rate for the first 15 minutes.
D. Document the transfusion in the patient's medical record immediately after administration.

Correct answer: C

Rationale: The correct answer is to administer the transfusion at a slow rate for the first 15 minutes. This practice is crucial as it helps in detecting any adverse reactions early on. Checking the patient's vital signs every 30 minutes (choice B) is important but not as essential as ensuring a slow rate at the beginning. Administering blood within 4 hours (choice A) is a standard practice but not directly related to the initial administration. Documenting the transfusion immediately (choice D) is necessary but does not directly impact the safety of the initial administration.

3. A nurse is providing teaching to the parent of a child who is receiving oral nystatin for oral candidiasis. Which of the following statements by the parent indicates an understanding of the teaching?

A. I will mix the medication with applesauce
B. I will provide a snack with the medication
C. I will store the medication in the refrigerator
D. I will swab the inside of my child's mouth with the medication

Correct answer: D

Rationale: The correct answer is D because swabbing the inside of the child's mouth with the nystatin solution is the correct administration method for treating oral candidiasis. Mixing the medication with applesauce or providing a snack with it is not the recommended method of administration. Storing the medication in the refrigerator is also unnecessary and not part of the proper administration instructions.

4. A patient is at risk for impaired skin integrity. What is the priority intervention for the nurse?

A. Turn and reposition the patient every 2 hours.
B. Apply a moisture barrier to the patient's skin.
C. Massage the patient's skin to promote circulation.
D. Apply a heating pad to the patient's skin to increase blood flow.

Correct answer: A

Rationale: The correct answer is to turn and reposition the patient every 2 hours. This intervention is crucial in preventing pressure ulcers and maintaining skin integrity by relieving pressure on bony prominences. Applying a moisture barrier (Choice B) is important for moisture-associated skin damage but is not the priority in this case. Massaging the patient's skin (Choice C) can potentially cause friction and shear, increasing the risk of skin breakdown. Applying a heating pad (Choice D) can lead to burns or thermal injuries, exacerbating skin integrity issues.

5. A nurse is caring for a client with pneumonia who has a new prescription for antibiotics. Which of the following actions should the nurse take first?

A. Administer the antibiotic immediately
B. Obtain a sputum culture
C. Notify the provider of the prescription
D. Check the client's allergy history

Correct answer: B

Rationale: The correct first action for the nurse to take when caring for a client with pneumonia who has a new prescription for antibiotics is to obtain a sputum culture. This is important to identify the specific bacteria causing the pneumonia before administering antibiotics. Administering the antibiotic immediately (Choice A) may not be appropriate without knowing the specific pathogen. Notifying the provider of the prescription (Choice C) is important but not the first action to be taken. Checking the client's allergy history (Choice D) is relevant but not the priority in this situation.