ATI RN
Client Comfort and End of Care ATI Questions
Question 1 of 5
What does the nurse recognize as the primary benefit of using a pain rating scale with clients?
Correct Answer: C
Rationale: The nurse recognizes that the primary benefit of a pain rating scale is allowing comparison over time, as it quantifies subjective pain (e.g., 0-10) consistently, tracking changes to assess treatment efficacy or pain progression. This aids longitudinal care. Choice A, reduces medication use, isn't directscales guide dosing, not inherently lower it. Choice B, provides objective data, is inaccurate; pain is subjectivescales standardize reporting, not objectify it. Choice D, eliminates need for observation, is falsescales complement, not replace, nonverbal cues (e.g., grimacing). Choice C is correct, reflecting nursing's reliance on scales (e.g., numeric, FACES) to monitor trendse.g., pain dropping from 8 to 4 post-interventionensuring dynamic, responsive management across acute or chronic cases.
Question 2 of 5
The nurse would expect a client receiving a nonopioid analgesic to report which of the following side effects?
Correct Answer: B
Rationale: The nurse expects gastrointestinal upset from a nonopioid analgesic (e.g., ibuprofen), as NSAIDs inhibit gastric prostaglandins, irritating the stomach lining, causing nausea or paina common side effect. Choice A, constipation, is opioid-related, not nonopioidNSAIDs don't slow gut motility. Choice C, sedation, suits narcotics or adjuvants (e.g., amitriptyline), not nonopioids, which lack CNS depression. Choice D, respiratory depression, is an opioid risk, not nonopioidNSAIDs don't affect breathing. Choice B is correct, prompting nurses to monitor GI symptoms, advising food intake or antacids to mitigate upset, ensuring nonopioid benefits (pain relief) outweigh this manageable drawback in acute or chronic use.
Question 3 of 5
When positioned properly, the tip of a central venous catheter should lie in the:
Correct Answer: A
Rationale: A central venous catheter (CVC) is inserted to deliver fluids, medications, or nutrition directly into large veins near the heart, and its tip placement is critical for safety and efficacy. The superior vena cava (Choice A) is the correct location, specifically near its junction with the right atrium but without crossing into it, ensuring rapid dilution of infused substances into central circulation. The basilica vein (Choice B) is a peripheral vein in the arm, unsuitable for a CVC's central purpose. The jugular vein (Choice C) and subclavian vein (Choice D) are common insertion sites, but the catheter's tip must advance beyond these entry points to the superior vena cava for proper function. Misplacement (e.g., too far into the right atrium) risks arrhythmias or perforation, while too proximal a position reduces effectiveness. Imaging (e.g., chest X-ray) confirms placement in the superior vena cava, balancing efficacy and safety. This anatomical precision makes Choice A the correct answer, reflecting standard practice in critical care nursing.
Question 4 of 5
A nurse assigned to care for a postoperative male client who has diabetes mellitus. During the assessment interview, the client reports that he's impotent and says that he's concerned about its effect on his marriage. In planning this client's care, the most appropriate intervention would be to:
Correct Answer: D
Rationale: For a postoperative diabetic client reporting impotence and marital concerns, the most appropriate intervention is suggesting referral to a sex counselor or professional (Choice D). Diabetes and surgery can cause erectile dysfunction (ED) via neuropathy, vascular damage, or psychological stress, requiring specialized expertise beyond general nursing. Encouraging questions (Choice A) fosters discussion but doesn't address the issue's complexity. Providing privacy (Choice B) supports dignity but doesn't resolve ED or marital strain. Supporting the spouse (Choice C) is secondary without addressing the client's primary concern. A sex counselor can assess physical and emotional factors, offer tailored therapies (e.g., medication, counseling), and involve the spouse, aligning with holistic care. Nurses facilitate referrals when issues exceed their scope, ensuring comprehensive management. Choice D directly tackles the client's stated worry, making it the correct and most effective intervention.
Question 5 of 5
A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to:
Correct Answer: A
Rationale: Blunt chest trauma from a motor vehicle accident can compromise airway, breathing, or circulation (ABCs), the nurse's top priorities. Assessing the client's airway (Choice A) is first because obstruction (e.g., from blood, swelling, or foreign objects) or injury (e.g., pneumothorax) threatens life within minutes. Signs like stridor, cyanosis, or absent breath sounds demand immediate actione.g., suctioning or intubation. Pain relief (Choice B) is vital but secondary, as unrelieved pain won't kill instantly, unlike airway loss. Encouraging deep breathing and coughing (Choice C) risks worsening injuries like rib fractures or flail chest if airway isn't secured. Splinting the chest (Choice D) aids breathing but assumes airway patency. For example, a tracheal deviation from tension pneumothorax detected during airway assessment takes precedence over pain. ABC prioritization ensures survival, making Choice A the correct first step.