what is the best intervention for a patient experiencing acute pain
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Nursing Elites

ATI RN

ATI RN Comprehensive Exit Exam

1. What is the most effective intervention for a patient experiencing acute pain?

Correct answer: A

Rationale: Administering analgesics is the most effective intervention for a patient experiencing acute pain as it directly targets the pain receptors and provides relief. Repositioning the patient may help in some cases, but it is not the primary intervention for managing acute pain. Non-pharmacological interventions can be beneficial as adjuncts to pain management but might not provide immediate relief. Administering IV fluids is not a standard intervention for acute pain unless dehydration is contributing to the pain.

2. A client practicing Orthodox Judaism informs the nurse they are observing the Passover holiday. Which action should the nurse include in the plan of care?

Correct answer: C

Rationale: During the Passover holiday, individuals practicing Orthodox Judaism follow dietary restrictions that include consuming unleavened bread. This symbolizes the haste with which the Israelites left Egypt and the lack of time for bread to rise. Providing chicken with cream sauce (Choice A) is not aligned with Passover dietary restrictions. Avoiding serving fish with fins and scales (Choice B) is a general dietary law in Judaism but not specific to Passover. Similarly, avoiding foods containing lamb (Choice D) is not a specific requirement during Passover.

3. A nurse is providing discharge teaching to a client who has a new prescription for enoxaparin. Which of the following instructions should the nurse include?

Correct answer: D

Rationale: The correct answer is to inject the medication into the abdomen. Enoxaparin should be administered subcutaneously into the abdomen for optimal absorption. Choice A is incorrect as there is no specific interaction between enoxaparin and spinach. Choice B is incorrect as massaging the injection site after administration is not recommended and can increase bruising. Choice C is incorrect as enoxaparin injections should not be administered into the deltoid muscle.

4. A nurse is preparing to perform postmortem care for a client. Which of the following actions should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse to take when preparing to perform postmortem care is to remove the client's IV lines. This step is essential to help maintain the dignity and appearance of the body. Placing the client's dentures in a labeled container (Choice A) is not a priority during postmortem care as the focus is on the body's preparation. While positioning the body in a semi-fowler's position (Choice C) or lowering the client's head of the bed (Choice D) are common practices for living clients to prevent aspiration, they are not necessary after death. Therefore, the immediate action of removing IV lines is most appropriate in this situation.

5. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take first?

Correct answer: A

Rationale: The correct first action for the nurse to take when preparing to administer a unit of packed RBCs is to check the client's identification band. This step is crucial to ensure that the correct blood is administered to the right client, preventing any errors or adverse reactions. Verifying the provider's prescription, priming the IV tubing, and obtaining the client's vital signs are important steps in the process but should follow the initial identification check to prioritize patient safety.

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