a nurse is caring for a client who reports burning around the peripheral iv site what finding should the nurse identify as a manifestation of infiltra
Logo

Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. A nurse is caring for a client who reports burning around the peripheral IV site. What finding should the nurse identify as a manifestation of infiltration?

Correct answer: B

Rationale: Edema at the IV site is a common sign of infiltration, where fluid leaks into the surrounding tissue. Bruising at the IV site (Choice A) is more indicative of hematoma formation, warmth along the IV site (Choice C) may suggest infection, and pallor at the IV site (Choice D) is not a typical sign of infiltration.

2. A nurse is caring for a client who has dementia and frequently tries to get out of bed. What actions should the nurse take? (Select all that apply)

Correct answer: C

Rationale: Maintaining the bed in the lowest position is an appropriate action when caring for a client with dementia who tries to get out of bed. This helps reduce the risk of falls and ensures the client's safety. Turning off the bed alarm (Choice A) is not advisable as it can be a safety measure to alert the staff when the client tries to get out of bed. Using physical restraints (Choice B) and applying a vest restraint (Choice D) should be avoided as they can lead to physical and psychological harm, reduce mobility, and compromise the client's dignity.

3. A healthcare professional is preparing to administer an intramuscular injection to a client. What is the appropriate site for the injection to avoid injury?

Correct answer: B

Rationale: The ventrogluteal site is the preferred site for intramuscular injections to avoid injury to nerves or blood vessels. The deltoid site is commonly used for vaccines but has a higher risk of hitting the radial nerve. The rectus femoris site is not typically recommended for intramuscular injections. The dorsogluteal site is contraindicated due to the proximity to the sciatic nerve and major blood vessels.

4. A client has a new prescription for a cane. What instruction should the nurse include?

Correct answer: B

Rationale: The correct instruction the nurse should include is to ensure the cane has a rubber tip. This is important as it prevents slipping and ensures safety while walking. Choice A is incorrect because the cane should be held on the stronger side to provide better support. Choice C is incorrect as the cane should be used on the stronger, not the dominant, side for stability. Choice D is incorrect because a cane can be used for support in various situations, not just on stairs.

5. A client who has recently developed fever, confusion, and a decreased level of consciousness is being admitted by a nurse. What should the nurse do first after obtaining the client's history and assessment?

Correct answer: C

Rationale: The correct answer is to identify the client's needs first. This allows the nurse to prioritize interventions based on the assessment findings. Administering prescribed antibiotics (choice A) should be based on a medical prescription and the identified infection. Initiating seizure precautions (choice B) is important but not the immediate priority in this case. Placing the client in isolation (choice D) is premature as the nurse needs to first assess and address the client's condition.

Similar Questions

A nurse is planning to administer several medications to a client through a nasogastric (NG) tube. What action should the nurse take?
A nurse is assessing a client who reports a burning sensation at the site of a peripheral IV. The site is red and swollen. What is the nurse's priority action?
A nurse is assessing a client who has received intermittent enteral feedings. What finding indicates the client is tolerating the feeding?
A nurse is planning to teach a group of older adults about the prevention of osteoporosis. What information should the nurse include in the teaching?
A client scheduled for cataract surgery tells the nurse, 'I see just fine and have decided to cancel my surgery.' What should the nurse do?

Access More Features

ATI RN Basic
$69.99/ 30 days

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

ATI RN Premium
$149.99/ 90 days

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

Other Courses