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. A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

A. Elevate the head of the bed no more than 45 degrees
B. Apply cornstarch to keep sensitive skin areas dry
C. Massage the skin over the client's bony prominences
D. Use a transfer device to lift the client up in bed

Correct answer: D

Rationale: The correct answer is to use a transfer device to lift the client up in bed. This intervention helps reduce friction and the risk of skin breakdown, aiding in the prevention of pressure ulcers. Elevating the head of the bed no more than 45 degrees can help with respiratory issues but does not directly address skin integrity. Applying cornstarch may lead to further skin irritation. Massaging over bony prominences can increase the risk of skin damage rather than maintaining skin integrity.

3. A nurse observes a colleague not using proper hand hygiene. What should the nurse do first?

A. Ignore the behavior and continue with care
B. Discuss the behavior with other colleagues
C. Confront the colleague about the behavior
D. Report the behavior to the supervisor

Correct answer: D

Rationale: The correct action for the nurse to take first is to report the behavior to the supervisor. Proper hand hygiene is essential in preventing the spread of infections in healthcare settings. By reporting the observed behavior to the supervisor, the nurse is prioritizing patient safety and promoting a culture of accountability. Ignoring the behavior (Choice A) can put patients at risk, discussing it with other colleagues (Choice B) may not address the issue effectively, and confronting the colleague directly (Choice C) might not be the most appropriate initial step and could lead to conflicts rather than a constructive resolution.

4. What is a key component of a comprehensive discharge plan for a patient with heart failure?

A. Advising on appropriate physical activity and exercise
B. Fluid restriction to prevent fluid overload
C. Dietary recommendations, including a low-sodium diet
D. Medication management, including diuretics and ACE inhibitors

Correct answer: A

Rationale: The main components of a comprehensive discharge plan for a patient with heart failure include advising on appropriate physical activity and exercise to improve cardiovascular health and overall well-being. While fluid restriction and dietary recommendations are important aspects of heart failure management, advising on physical activity and exercise is crucial for improving cardiac function and quality of life post-discharge. Medication management is also essential but focusing on physical activity is particularly relevant for long-term management and preventing readmissions.

5. What should be done to manage a patient with contact precautions?

A. Wear a mask, gown, and gloves for all patient interactions.
B. Ensure that visitors wear protective equipment.
C. Dedicate all patient care equipment to that patient.
D. Disinfect shared equipment before use.

Correct answer: C

Rationale: When managing a patient with contact precautions, it is essential to dedicate all patient care equipment to that specific patient. This practice helps minimize the risk of spreading infections to other patients. Choice A, wearing protective gear for all patient interactions, is a general precaution but not specific to managing a patient with contact precautions. Choice B, ensuring visitors wear protective equipment, is important for infection control but not directly related to managing the patient with contact precautions. Choice D, disinfecting shared equipment before use, is a good practice for infection control in general but does not address the specific needs of a patient under contact precautions.