a nurse is admitting a client who has recently developed fever confusion and a decreased level of consciousness which of the following actions should
Logo

Nursing Elites

ATI LPN

PN ATI Capstone Fundamentals Quiz

1. When admitting a client with fever, confusion, and decreased level of consciousness, what should the nurse do first after obtaining the client's history and assessment?

Correct answer: A

Rationale: When a client presents with fever, confusion, and decreased level of consciousness, the first step should be to identify the client's needs. This involves recognizing any immediate concerns or issues that require urgent attention. Starting intravenous fluids, notifying the provider, or conducting a neurological assessment may be necessary actions but should come after identifying the client's needs to ensure proper prioritization of care.

2. A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client’s contractions are occurring every 45 seconds with a duration of 90 seconds, and the fetal heart rate is 170-180/minute. Which of the following actions should the nurse take?

Correct answer: A

Rationale: In this scenario, the contractions are too frequent (tachysystole), and the fetal heart rate is elevated. Tachysystole can lead to decreased oxygen perfusion to the fetus, causing fetal distress. Therefore, the correct action for the nurse to take is to discontinue the oxytocin infusion to prevent harm to both the mother and fetus. Increasing or maintaining the oxytocin infusion would exacerbate the current situation, potentially leading to further complications. Decreasing the oxytocin infusion may not be sufficient to address the tachysystole and elevated fetal heart rate, making it an inappropriate choice.

3. A nurse is preparing to administer an intramuscular injection to an adult client. At what angle should the nurse administer the medication using the ventrogluteal site?

Correct answer: A

Rationale: The correct answer is A: 90-degree angle. The ventrogluteal site is preferred for intramuscular injections because it is away from major nerves and blood vessels. Administering the injection at a 90-degree angle ensures that the medication reaches deep into the muscle tissue, allowing for proper absorption of the drug. Choice B, 60-degree angle, is incorrect as it is not the recommended angle for the ventrogluteal site. Choice C, 75-degree angle, and Choice D, 45-degree angle, are also incorrect as they are not the appropriate angles for administering an intramuscular injection using the ventrogluteal site.

4. A nurse is assessing a client for signs of hypokalemia. Which of the following findings should the nurse look for?

Correct answer: A

Rationale: Muscle weakness is a classic sign of hypokalemia. Potassium plays a crucial role in muscle function, and low potassium levels can lead to muscle weakness. Weight gain, elevated blood pressure, and increased thirst are not typically associated with hypokalemia. Weight gain can be seen in conditions like fluid retention, elevated blood pressure can result from various causes, and increased thirst may be a symptom of conditions like diabetes.

5. A nurse is providing education on the use of calcium carbonate. Which of the following should be included?

Correct answer: B

Rationale: The correct answer is B: 'Monitor for constipation.' Calcium carbonate can cause constipation as a side effect. Educating clients on dietary adjustments, such as increasing fluid intake and fiber consumption, can help alleviate this issue. Choice A is incorrect because calcium carbonate supplementation is used to treat hypocalcemia, not cause it. Choice C is incorrect because calcium carbonate should be taken with food for optimal absorption. Choice D is incorrect because calcium carbonate is available over the counter, not as a prescription medication.

Similar Questions

A nurse is preparing to administer medications to a client who is NPO and has an NG tube for suction. Which of the following actions should the nurse take?
A nurse is providing discharge instructions to parents of a circumcised newborn. To prevent diaper adherence to the penis, what will be recommended to apply during diaper changes?
A nurse is caring for a client in active labor who is receiving oxytocin. The nurse notes that the client is experiencing contractions every 1 minute lasting 90 seconds. Which of the following actions should the nurse take?
A client is being educated about the use of spironolactone. Which of the following should be included in the teaching?
A healthcare professional is assessing a client for potential complications after surgery. Which of the following should the healthcare professional monitor for?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses