what is the most appropriate method for assessing a patients pain level
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN

1. What is the most appropriate method for assessing a patient's pain level?

Correct answer: B

Rationale: The most appropriate method for assessing a patient's pain level is to use a standardized pain scale, such as a 0-10 scale. This method provides an objective and consistent way to measure and communicate the intensity of pain experienced by the patient. Choice A, observing facial expressions, can be subjective and may not always accurately reflect the level of pain. Choice C, asking the patient to rate their pain based on their mood, may be influenced by various factors unrelated to pain. Choice D, involving the patient's family members in assessing the pain, is not ideal as pain is a subjective experience that should be reported by the patient themselves.

2. What are the main differences between a stroke caused by ischemia and one caused by hemorrhage?

Correct answer: A

Rationale: The correct answer is A: "Blockage in a blood vessel supplying the brain." Ischemic stroke is caused by a blockage in a blood vessel supplying the brain, leading to reduced blood flow. Hemorrhagic stroke, on the other hand, is caused by bleeding in the brain due to a ruptured blood vessel. Choices B, C, and D are incorrect. Administering thrombolytics, avoiding anticoagulants, and preparing for surgery are specific management strategies that may apply to ischemic or hemorrhagic strokes but do not define the main differences between the two types of strokes.

3. A nurse is preparing to administer medications to a client via a nasogastric (NG) tube. What should the nurse do first?

Correct answer: B

Rationale: The correct answer is B: 'Flush the NG tube before and after each medication.' Flushing the NG tube is essential to ensure that the medication passes through smoothly without any obstruction. It helps prevent clogging of the tube and ensures that the full dose of the medication reaches the patient. Options A, C, and D are incorrect because crushing all medications at once, administering only liquid forms of medications, and skipping tube flushing entirely can lead to complications such as tube blockages, incomplete medication administration, and potential harm to the client.

4. A nurse discovers a discrepancy in the narcotics log. What is the appropriate next step?

Correct answer: B

Rationale: When a nurse discovers a discrepancy in the narcotics log, the appropriate next step is to report the discrepancy to the nurse manager. This is important to ensure that the issue is properly investigated and addressed. Choice A is incorrect because simply correcting the log and notifying the pharmacy may not address the root cause of the discrepancy. Choice C is incorrect as re-administering the narcotic without clarification could lead to potential harm or legal issues. Choice D is incorrect as disposing of the narcotic without following proper protocols and documentation could result in further complications.

5. A patient has an ankle restraint applied. Upon assessment, the nurse finds the toes a light blue color. Which action will the nurse take next?

Correct answer: D

Rationale: The correct answer is to remove the restraint (Choice D). Cyanosis of the toes, indicated by a light blue color, suggests impaired circulation. The priority action is to ensure proper circulation by removing the restraint to prevent further compromise. Choices A and B are not the immediate actions needed for cyanosis related to impaired circulation. Choice C, placing a blanket over the feet, does not address the underlying issue of impaired circulation and could delay appropriate intervention.

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