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. If a patient's blood pressure is 150/96, what is his pulse pressure?

Correct answer: A

Rationale: Pulse pressure is calculated by subtracting the diastolic pressure from the systolic pressure. In this case, the systolic pressure is 150 and the diastolic pressure is 96. Therefore, the pulse pressure is 150 - 96 = 54. Pulse pressure represents the force generated by the heart with each contraction and is an important indicator of cardiovascular health.

3. All of the following interventions are correct when using the Z-track method of drug injection except:

Correct answer: D

Rationale: When using the Z-track method of drug injection, it is important to prepare the injection site with alcohol to ensure cleanliness, use a needle that is at least 1” long to reach the muscle tissue, and aspirate for blood before injection to verify correct needle placement. However, rubbing the site vigorously after the injection is not recommended as it can cause medication to leak into subcutaneous tissue, compromising the medication's intended absorption and efficacy.

4. For abdominal inspection, in which of the following positions should a patient be placed?

Correct answer: C

Rationale: The supine position is ideal for abdominal inspection as it allows the healthcare provider to easily access and examine the abdomen. In the supine position, the patient lies flat on their back with arms at their sides, providing a clear view and access to the abdominal area for inspection.

5. When teaching a client with tuberculosis, which statement should the nurse include?

Correct answer: B

Rationale: Monitoring the effectiveness of tuberculosis medication is crucial to ensure the treatment is working properly. Regular sputum samples help in assessing the response to the medication. This monitoring can guide adjustments in the treatment plan if needed. Options A and C are incorrect as they do not reflect essential aspects of tuberculosis treatment. Option D is not a standard recommendation for tuberculosis treatment and may lead to misconceptions.

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