ATI Swift River Test Practice Exam

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When a patient reports an escalation in pain from 2/10 to 8/10, what is the first action the nurse should take?

Administer pain medication

Assess his vital signs

In a situation where a patient reports a significant increase in pain, it's essential for the nurse to first assess the patient's current condition comprehensively. Notably, assessing vital signs is crucial because it provides immediate information about the patient’s physiological status. An escalation in pain can be indicative of various underlying issues such as infection, internal bleeding, or complications related to the patient's condition.

By checking vital signs, the nurse can determine if the patient is experiencing any acute changes that may require urgent intervention beyond pain management. For instance, vital signs such as elevated heart rate or blood pressure can suggest pain-related stress or even a response to internal issues that might be happening concurrently. This assessment helps create a complete picture of the patient's situation and guides subsequent actions.

Once vital signs are evaluated and documented, the nurse can make a more informed decision about the appropriate interventions, which may include pain management with medication if necessary. Prioritizing vital signs ensures that any significant issues are identified early, allowing for a swift response to potential complications.

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Encourage the use of incentive spirometry

Check his chest drainage system

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