a nurse is completing an admission assessment for a client who has hearing loss what action should the nurse take
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Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. A nurse is completing an admission assessment for a client who has hearing loss. What action should the nurse take?

Correct answer: A

Rationale: Using written communication is the most effective action for a nurse when assessing a client with hearing loss. This method helps overcome communication barriers by providing information visually, ensuring the client understands the assessment questions and instructions. Speaking louder (choice B) may distort the sound and not necessarily improve understanding. Facing the client (choice C) is important for lip reading but may not be sufficient for effective communication. Providing care in a quiet environment (choice D) is beneficial but might not fully address the need for clear communication in the assessment process for a client with hearing loss.

2. A nurse is providing discharge instructions to a client with chronic obstructive pulmonary disease (COPD). What instruction should the nurse include to help improve oxygenation?

Correct answer: B

Rationale: The correct answer is B: 'Use pursed-lip breathing during activities.' Pursed-lip breathing improves oxygenation by keeping airways open longer, facilitating better exhalation of carbon dioxide. Choice A is incorrect because avoiding physical activity can lead to deconditioning and worsen oxygenation. Choice C is irrelevant to improving oxygenation in COPD. Choice D is not directly related to improving oxygenation in COPD; weight-bearing exercises are important for bone health but not for oxygenation.

3. A client expresses anxiety about an upcoming surgery. What should the nurse do?

Correct answer: B

Rationale: When a client expresses anxiety, it is essential for the nurse to encourage the client to verbalize their feelings. This helps the client express concerns, fears, and uncertainties, enabling the nurse to provide appropriate emotional support. Administering a sedative (Choice A) should not be the initial response as it does not address the underlying emotional needs of the client. Calling the surgeon to address anxiety (Choice C) may not be within the nurse's scope of practice and may not directly address the client's emotional needs. Providing information on post-op care (Choice D) is important but not the priority when the client is experiencing anxiety preoperatively.

4. A healthcare professional is preparing to transfer a client from a chair to the bed. The client can bear partial weight and has upper body strength. Which device should the professional use?

Correct answer: C

Rationale: A stand-assist lift is the most suitable device for transferring a client who can bear partial weight and has upper body strength. This lift provides support and assistance for clients to stand up and be safely transferred. A gait belt is used for providing support during walking or transferring short distances for clients who need minimal assistance with balance and strength. A mechanical lift is typically used for clients who are non-weight bearing or have limited weight-bearing capacity. A slide board is utilized for transferring clients who are unable to bear weight on their legs and need assistance in sliding from one surface to another.

5. 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.

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