a nurse is assessing a client who is experiencing auditory hallucinations what question should the nurse ask
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Nursing Elites

ATI RN

ATI Exit Exam 2023 Quizlet

1. A nurse is assessing a client who is experiencing auditory hallucinations. What question should the nurse ask?

Correct answer: D

Rationale: Exploring strategies to ignore the hallucinations can help clients manage symptoms.

2. A healthcare professional is reviewing the medical record of a client who has a new prescription for ceftriaxone. The healthcare professional should identify which of the following findings as a contraindication to this medication?

Correct answer: C

Rationale: The correct answer is C: Penicillin allergy. Penicillin allergy is a contraindication for ceftriaxone because both medications are beta-lactam antibiotics. Seizure disorder (choice A), hypertension (choice B), and hyperlipidemia (choice D) are not contraindications for ceftriaxone and do not directly affect the use of this antibiotic.

3. What is the most appropriate action when a patient experiences a fall in the hospital?

Correct answer: A

Rationale: The correct answer is to assess the patient for injuries. When a patient experiences a fall in the hospital, the immediate concern is to check for any injuries that may require urgent care. Calling for help can be done after assessing the patient to ensure appropriate assistance is provided. Documenting the fall is important for the patient's medical record, but it is not the most immediate action needed. Notifying the healthcare provider can come after the initial assessment to update them on the situation.

4. A client with heart failure is receiving discharge teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?

Correct answer: C

Rationale: The correct answer is C. Reporting a sudden weight gain of 2 pounds in one day is crucial in managing heart failure because it can indicate fluid retention, a common symptom in heart failure. Option A is incorrect as weighing oneself once a week may not provide timely information about fluid retention. Option B is incorrect because fluid intake restriction is individualized and generally involves more specific guidance. Option D is incorrect as protein intake is important but reducing it solely to avoid fluid retention is not the primary focus in heart failure management.

5. A nurse in an emergency department is assessing a newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following actions should the nurse take first?

Correct answer: D

Rationale: In a client experiencing drooling and hoarseness following a burn injury, the priority action for the nurse is to administer 100% humidified oxygen. This is crucial to maintain the airway and address respiratory distress, which takes precedence over obtaining an ECG, collecting blood for ABG analysis, or inserting an IV catheter. Providing oxygen therapy is essential in ensuring the client's oxygenation and respiratory function are optimized in this emergency situation.

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