a nurse is caring for a client who has vision loss which of the following actions should the nurse not take
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Nursing Elites

ATI RN

ATI Fundamentals Proctored Exam 2023

1. A client with vision loss is under the care of a nurse. Which of the following actions should the nurse AVOID?

Correct answer: C

Rationale: Approaching a client with vision loss from the side can startle them and may lead to accidents or discomfort. It is important to approach them from the front so they are aware of your presence. Keeping objects in the same place aids in familiarity and reduces the risk of falls. High-wattage lighting enhances visibility for the client. Allowing extra time for tasks accommodates the client's potential slower pace and ensures they can perform tasks safely.

2. Which of the following is a sign or symptom of a hemolytic reaction to a blood transfusion?

Correct answer: A

Rationale: Hemoglobinuria is a characteristic sign of a hemolytic reaction to a blood transfusion. Hemolytic reactions can lead to the destruction of red blood cells, causing the release of hemoglobin into the urine, which presents as hemoglobinuria. Chest pain, urticaria, and distended neck veins are not specific signs of a hemolytic reaction and may be associated with other conditions or reactions.

3. How many ounces are in 1 cup?

Correct answer: A

Rationale: 1 cup is equivalent to 8 ounces. This conversion is commonly used in cooking and baking recipes, where precise measurements are crucial for the successful outcome of dishes. Knowing this conversion helps ensure that ingredients are accurately measured and the recipe turns out as intended. Choices B, C, and D are incorrect because they do not reflect the correct conversion between cups and ounces. 80, 800, and 8000 ounces are significantly higher quantities than what is found in 1 cup, which is 8 ounces.

4. Studies have shown that about 40% of patients fall out of bed despite the use of side rails; this has led to which of the following conclusions?

Correct answer: D

Rationale: The correct conclusion drawn from the study is that side rails serve as a reminder to the patient not to get out of bed rather than being a fail-proof preventive measure against falls. While they may not entirely prevent falls, they play a role in prompting the patient to be cautious when moving.

5. Which of the following actions should be taken to use a wide base support when assisting a client to get up in a chair?

Correct answer: C

Rationale: The correct answer is C: Spread the feet apart. When assisting a client to get up in a chair, it is crucial to use a wide base of support to maintain stability and prevent injuries. Spreading the feet apart provides a broader base, increasing balance and support for both the client and the caregiver. This position helps distribute the weight evenly and allows for better control when assisting the client in moving. Choices A, B, and D are incorrect because bending at the waist, placing arms under the client's arms, tightening pelvic muscles, or placing hands on the client's forearm do not provide the necessary wide base support needed for stability and safety during the transfer process.

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