ATI RN
ATI NUR 180 Pharmacology Exam Questions
Extract:
Nurses Notes
Vital Signs
Medication Administration Record (MAR)
The client arrived at the unit at 1000. He is alert and oriented x4. He reports mild pain at the surgical site, rated as 2 out of 10 on the pain scale. Peripheral IV is located on the left forearm with good blood return and flushes without difficulty. Vital signs are stable. The client denies nausea or vomiting.
Question 1 of 5
A nurse is caring for a 78-year-old male client admitted to the Surgical unit after having a total right knee replacement. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress. Condition Choices: A. Post-operative pain, B. Post-operative nausea and vomiting, C. Surgical site infection, D. Deep vein thrombosis (DVT), E. Actions to take Choices: A. Administer acetaminophen (Tylenol) for mild pain., B. Apply a warm compress to the surgical site., C. Encourage ambulation to prevent DVT., D. Monitor for signs of infection at the surgical site., E. Administer ondansetron (Zofran) for nausea. Parameters to monitor Choices: A. Pain level on a 0-10 scale., B. Respiratory rate., C. Oxygen saturation., D. Surgical site appearance., E. Urine output.
| Condition:A. Post-operative pain B. Post-operative nausea and vomiting C. Surgical site infection D. Deep vein thrombosis (DVT) |
| Actions to take: A. Administer acetaminophen (Tylenol) for mild pain. B. Apply a warm compress to the surgical site. C. Encourage ambulation to prevent DVT. D. Monitor for signs of infection at the surgical site. E. Administer ondansetron (Zofran) for nausea. |
| Parameters to monitor: A. Pain level on a 0-10 scale. B. Respiratory rate. C. Oxygen saturation. D. Surgical site appearance. E. Urine output. |
Correct Answer: A,A,B,A
Rationale: The correct answer is - A,A,B,A.
Rationale:
1. Post-operative pain is a common issue after knee replacement surgery. Administering acetaminophen helps manage mild pain.
2. Monitoring the surgical site appearance is crucial to detect signs of infection early for prompt intervention.
3. Encouraging ambulation is essential to prevent complications like DVT due to immobility.
4. Pain level on a 0-10 scale should be monitored to assess the effectiveness of pain management and the client's comfort.
Summary of other choices:
- Post-operative nausea and vomiting (
B) is not the most likely condition for a client after knee replacement surgery.
- Surgical site infection (
C) is important to monitor but not the most likely condition immediately post-surgery.
- Deep vein thrombosis (DVT) (
D) is a possible complication, but ambulation is a more direct preventive measure.
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Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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