2024 ATI N URS 142 Final Exam New Latest Version with All Q uestions from Actual Past Exa m and 100% Correct Answ ers Question 1: The nurse is caring for two clients who both are in pain due to sickle cell anemia. One of the clients rates the pain as a 7 out of 10 (0 is no pain and 10 is the worst pain possible). This client is moving around easily and is eating well, but has asked f or pain medication. Which action by the nurse is most appropriate? A. Notify the healthcare provider that this client is faking the pain. B. Administer the pain medication if it has been longer than the ordered inter val. C. Wait 30 minutes and see if the client is still requesting pain medicine. D. Administer half the ordered dose of pain medication. Show correct answer and explanation Explanation Pain is a subjective experience, and the client's report of pain should be respected and addressed promptly. If the pain medication is ordered and it has been longer than the ordered interval, the nurse should administer the medication as prescribed. In ge neral, withholding pain medication for a client in pain is not an appropriate action. Administering half the ordered dose of pain medication without a healthcare provider's order is also not appropriate. The nurse should follow the healthcare provider's orders for pain medication administration and titration. It's also not appropriate to assume that the client is faking pain without adequate assessment and evidence to support such a claim. The nurse should perform a thorough pain assessment, including the location, intensity, and quality of the pain, and consid er non -pharmacological interventions to help manage the pain. Question 2: The nurse is assessing the patient's lips and notes a bluish tinge. This finding would indicate that the patient may be experiencing which problem? A. Inflammation of the lips B. Hypoxia C. Beginning of a liver blister D. Lack of dental care Show correct answer and explanation Explanation Hypoxia is a medical condition characterized by a lack of oxygen in the body's tissues, which can occur due to a variety of reasons, such as respiratory failure, cardiac arrest, or other serious medical conditions. Cyanosis occurs when the oxygen saturatio n level in the blood falls below 85%, which causes a bluish color to appear on the skin, especially on the lips and fingertips. Therefore, if a nurse observes cyanosis in a patient's lips, it is a significant sign of hypoxia, and the patient requires immed iate medical attention. Question 3: When assessing the abdomen, the nurse would expect to auscultate which sounds? A. High -pitched gurgling B. Bruits C. Friction rubs. D. Low-pitched sonorous sounds Show correct answer and explanation Explanation When assessing the abdomen, the nurse would expect to auscultate bowel sounds, which are the sounds made by the movement of gas and fluid through the intestines. The normal bowel sounds are characterized as high -pitched, gurgling, and occurring at a rate of 5-30 sounds per minute. Bruits are abnormal sounds indicating turbulent blood flow and are usually assessed in other areas of the body, such as the epigastric and renal arteries, as well as in the aorta. Friction rubs are also abnormal sounds, but they are typically heard during auscultation of the heart and lungs. Low-pitched sonorous sounds are not typical sounds that are expected to be heard during an abdominal assessment Question 4: The nurse is performing a nutritional assessment. Which of the following would be considered objective data? A. Dietary history from patient B. Patient complaint of weight loss C. Body Mass Index (BMI) D. Patient history of alcohol intake Show correct answer and explanation Explanation
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