a nurse is caring for a client who reports difficulty sleeping while in the hospital which of the following actions taken by the assistive personnel a
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment Form A

1. A client reports difficulty sleeping while in the hospital. Which of the following actions taken by the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene?

Correct answer: B

Rationale: The correct answer is B because flushing the client's toilet after emptying the urinary catheter's drainage bag could disturb the client's rest. The nurse should intervene to ensure a restful environment for the client. Choices A, C, and D are not actions that would be disruptive to the client's sleep. Closing the door to the client's room, measuring vital signs routinely, and asking personnel in the hall to speak quietly are appropriate actions that do not directly disturb the client's rest.

2. A nurse is caring for a client with pneumonia who has a new prescription for antibiotics. Which of the following actions should the nurse take first?

Correct answer: B

Rationale: The correct first action for the nurse to take when caring for a client with pneumonia who has a new prescription for antibiotics is to obtain a sputum culture. This is important to identify the specific bacteria causing the pneumonia before administering antibiotics. Administering the antibiotic immediately (Choice A) may not be appropriate without knowing the specific pathogen. Notifying the provider of the prescription (Choice C) is important but not the first action to be taken. Checking the client's allergy history (Choice D) is relevant but not the priority in this situation.

3. A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take in accordance with hospital policy?

Correct answer: B

Rationale: The correct answer is B because patients on fall precautions need continuous monitoring until discharge to prevent falls. While encouraging visitors during visiting hours (Choice A) is important for the patient's well-being, it is not related to fall precautions. Checking on the patient every shift (Choice C) is an essential nursing intervention, but keeping the patient on fall precautions is more specific to preventing falls. Raising all four side rails (Choice D) is not recommended as it can restrict the patient's mobility and is considered a restraint practice.

4. A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?

Correct answer: B

Rationale: The correct answer is to inject enoxaparin subcutaneously at a 45-degree angle. This angle helps ensure proper delivery of the medication into the subcutaneous tissue. Option A (Inject at a 90-degree angle) is incorrect because subcutaneous injections are usually given at a shallower angle. Option C (Massage the injection site after administering) is incorrect as massaging the site can cause bruising and should generally be avoided. Option D (Use a longer needle) is incorrect as using a longer needle is unnecessary and may increase the risk of injecting the medication too deeply.

5. What is a recommended nursing action for a client who experiences short-term memory loss after Electroconvulsive Therapy (ECT)?

Correct answer: B

Rationale: The correct nursing action for a client experiencing short-term memory loss after ECT is to offer frequent orientation and reassurance. This helps the client feel supported and aids in memory retention. Providing cognitive-behavioral therapy (Choice A) may be beneficial for other conditions but is not the primary intervention for memory loss post-ECT. Administering a sedative (Choice C) is not recommended as it may further affect memory recall. Referring the client to a neurologist (Choice D) for further evaluation is not the initial action needed; offering support and orientation should be the first approach to manage memory issues post-ECT.

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