a nurse is caring for a patient with heart failure who has developed pulmonary edema what is the nurses priority action
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Nursing Elites

ATI RN

ATI Capstone Comprehensive Assessment B

1. A nurse is caring for a patient with heart failure who has developed pulmonary edema. What is the nurse's priority action?

Correct answer: B

Rationale: The correct answer is to place the patient in a high Fowler's position. This position helps improve lung expansion and oxygenation in cases of pulmonary edema by reducing venous return to the heart and enhancing respiratory mechanics. Administering a diuretic (Choice A) can be important but is not the priority over positioning in this situation. Administering oxygen (Choice C) is essential, but the priority action for improving oxygenation is the positioning of the patient. Monitoring lung sounds (Choice D) is crucial for ongoing assessment but is not the priority action when the patient is in distress with pulmonary edema.

2. A nurse is preparing a client for surgery. The client refuses to remove a religious medal. What is the nurse's best response?

Correct answer: C

Rationale: The correct answer is to allow the client to keep the medal during surgery. Clients may retain religious medals or jewelry during surgery if it does not interfere with the procedure. Asking the family to remove the medal (Choice A) may not be respecting the client's wishes. Placing the medal in a safe place for the client (Choice B) may cause distress to the client who wants to keep it. Informing the client that the medal must be removed (Choice D) disregards the client's beliefs and preferences.

3. A nurse discovers a discrepancy in the narcotics log. What is the appropriate next step?

Correct answer: B

Rationale: When a nurse discovers a discrepancy in the narcotics log, the appropriate next step is to report the discrepancy to the nurse manager. This is important to ensure that the issue is properly investigated and addressed. Choice A is incorrect because simply correcting the log and notifying the pharmacy may not address the root cause of the discrepancy. Choice C is incorrect as re-administering the narcotic without clarification could lead to potential harm or legal issues. Choice D is incorrect as disposing of the narcotic without following proper protocols and documentation could result in further complications.

4. A nurse is preparing to administer a blood transfusion. What is the most important action to ensure patient safety?

Correct answer: B

Rationale: The most important action to ensure patient safety when administering a blood transfusion is to verify the patient's identity with two identifiers before starting the transfusion. This step is crucial to prevent transfusion errors, such as giving the blood to the wrong patient. Checking vital signs, ensuring timely administration, and confirming informed consent are also important aspects of blood transfusion safety but verifying the patient's identity is the highest priority to prevent errors.

5. A staff nurse is challenging a shift assignment with the charge nurse. Which of the following statements made by the charge nurse is an example of smoothing as a strategy to resolve conflict?

Correct answer: D

Rationale: The correct answer is D because it exemplifies smoothing as a conflict resolution strategy. Smoothing involves downplaying conflict and reassuring the individual to reduce tension. In this statement, the charge nurse acknowledges the staff nurse's experience and capability to perform the assigned tasks, which aims to reduce conflict and promote a positive outlook. Choices A, B, and C do not reflect smoothing. Choice A involves a conditional agreement, choice B introduces a threat of reporting, and choice C shifts the focus away from the conflict.

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