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Ati nurse 142 final
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 for pain medication.
Which action by the nurse is most appropriate?
A. Notify the healthcare provider that this client is faking the pain. 0%
B. Administer the pain medication if it has been longer than the ordered interval. 100%
Most selected
C. Wait 30 minutes and see if the client is still requesting pain medicine. 0%
D. Administer half the ordered dose of pain medication. 0%
Answer and Explanation
Choice B:
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 general,
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 consider
non-pharmacological interventions to help manage the pain.
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 0%
B. Hypoxia 100% Most selected
C. Beginning of a liver blister 0%
D. Lack of dental care 0%
Answer and Explanation
Choice B:
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 saturation 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 immediate medical attention.
, When assessing the abdomen, the nurse would expect to auscultate which sounds?
A. High-pitched gurgling 100% Most selected
B. Bruits 0%
C. Friction rubs. 0%
D. Low-pitched sonorous sounds 0%
Answer and Explanation
Choice A:
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.
Ati nurse 142 final
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 for pain medication.
Which action by the nurse is most appropriate?
A. Notify the healthcare provider that this client is faking the pain. 0%
B. Administer the pain medication if it has been longer than the ordered interval. 100%
Most selected
C. Wait 30 minutes and see if the client is still requesting pain medicine. 0%
D. Administer half the ordered dose of pain medication. 0%
Answer and Explanation
Choice B:
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 general,
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 consider
non-pharmacological interventions to help manage the pain.
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 0%
B. Hypoxia 100% Most selected
C. Beginning of a liver blister 0%
D. Lack of dental care 0%
Answer and Explanation
Choice B:
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 saturation 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 immediate medical attention.
, When assessing the abdomen, the nurse would expect to auscultate which sounds?
A. High-pitched gurgling 100% Most selected
B. Bruits 0%
C. Friction rubs. 0%
D. Low-pitched sonorous sounds 0%
Answer and Explanation
Choice A:
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.
