a client with a history of substance abuse is admitted for detoxification which intervention is most important during the initial assessment
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Nursing Elites

ATI LPN

ATI PN Adult Medical Surgical 2019

1. During the initial assessment of a client with a history of substance abuse admitted for detoxification, which intervention is most important?

Correct answer: C

Rationale: Assessing the client's physical health status is the most critical intervention during the initial assessment of a client with a history of substance abuse admitted for detoxification. This evaluation helps identify and address any immediate health risks, such as withdrawal symptoms or medical complications, to ensure the client's safety and well-being during the detoxification process. Option A, obtaining a detailed substance use history, is important but not the most critical initially. Option B, establishing a trusting nurse-client relationship, is important but assessing physical health takes precedence. Option D, determining the client's readiness for change, is valuable but assessing physical health for immediate risks is the priority.

2. A healthcare professional is participating in the emergency care of a client who has just developed variceal bleeding. What intervention should the healthcare professional anticipate?

Correct answer: D

Rationale: The correct intervention for variceal bleeding is IV administration of octreotide. Octreotide helps control bleeding from varices by reducing portal blood flow and pressure, which is crucial in managing this emergency situation.

3. A patient with chronic heart failure is prescribed carvedilol. What is the primary purpose of this medication?

Correct answer: C

Rationale: Carvedilol, a beta-blocker, is primarily prescribed in patients with chronic heart failure to decrease heart rate and reduce the workload on the heart. By lowering the heart rate, carvedilol helps the heart function more efficiently and improves symptoms in patients with heart failure.

4. A client with a history of atrial fibrillation is prescribed dabigatran (Pradaxa). Which instruction should the nurse include in the client's teaching?

Correct answer: C

Rationale: The correct instruction for the nurse to include in the client's teaching regarding dabigatran (Pradaxa) is to take the medication at the same time each day. This ensures a consistent blood level and effectiveness of the medication, which is crucial in managing atrial fibrillation and preventing complications. It helps maintain a steady therapeutic effect and reduces the risk of erratic drug levels in the body.

5. The client is receiving intravenous vancomycin. Which assessment finding should the nurse report immediately?

Correct answer: A

Rationale: Red man syndrome is a severe and potentially life-threatening reaction to vancomycin characterized by flushing, rash, and hypotension. Immediate intervention is required to prevent further complications such as anaphylaxis. Therefore, the nurse should report this finding immediately to ensure prompt treatment and prevent serious adverse effects.

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