a nurse is providing discharge instructions to a client who has a new prescription for codeine for cough suppression what is the priority instruction
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN

1. A nurse is providing discharge instructions to a client who has a new prescription for codeine for cough suppression. What is the priority instruction?

Correct answer: C

Rationale: The correct answer is to instruct the client to 'Move slowly when standing up.' Codeine can cause orthostatic hypotension, a drop in blood pressure when changing positions, leading to dizziness or fainting. By advising the client to move slowly when standing up, the nurse helps prevent falls or injuries due to sudden drops in blood pressure. Choices A, B, and D are important instructions as well but not the priority when considering the risk of orthostatic hypotension associated with codeine.

2. A nurse is caring for a client who is postoperative and has compression stockings. Which action should the nurse take?

Correct answer: A

Rationale: The correct action for the nurse to take is to check the stockings for wrinkles. This is important to ensure that the stockings are applied correctly without any folds or wrinkles, which can hinder proper circulation and compression. Option B is incorrect because compression stockings should be applied with the client lying down, not sitting in a chair. Option C is unnecessary as the size of the client's foot is unlikely to change postoperatively. Option D is incorrect as compression stockings are usually worn continuously except for specific care needs.

3. A nurse on a rehabilitation unit is creating a plan of care for a newly admitted client who has difficulty swallowing following a stroke. Which of the following inter-professional team members should the nurse anticipate consulting regarding the client's condition?

Correct answer: A

Rationale: The correct answer is A, Speech-language pathologist. A speech-language pathologist specializes in evaluating and treating swallowing difficulties, known as dysphagia, which commonly occurs following a stroke. They are experts in developing strategies to help individuals improve their ability to swallow safely. Occupational therapists (B) focus on helping individuals regain independence in activities of daily living, not specifically addressing swallowing concerns. Dietitians (C) primarily work on developing appropriate nutrition plans but may not directly address swallowing issues. Pharmacy technicians (D) assist pharmacists in dispensing medications and are not directly involved in managing swallowing difficulties.

4. What is the most important action for the nurse to take before administering digoxin to a patient?

Correct answer: A

Rationale: The correct answer is to check the patient's heart rate before administering digoxin. Digoxin is a medication that primarily affects cardiac function. Monitoring the heart rate is crucial because digoxin can cause arrhythmias or worsen existing heart rhythm abnormalities. Assessing blood pressure may also be important but is secondary to evaluating the heart rate when administering digoxin. Ensuring the patient has eaten before administration is not directly related to the safe administration of digoxin. Monitoring the patient's weight is not a priority action before administering digoxin.

5. A nurse enters a client's room and finds the client pulseless. The client's living will requests no resuscitation be performed, but the provider has not written the prescription. Which of the following actions should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to begin CPR. In the absence of a written DNR order by the provider, the nurse is ethically and legally obligated to initiate CPR to attempt to save the client's life. Administering emergency medications without CPR (Choice A) may not address the immediate need for life-saving measures. Calling the provider for a DNR order (Choice C) may cause a delay in providing necessary resuscitative measures. Respecting the client's wishes and not attempting CPR (Choice D) goes against the nurse's duty to provide immediate life-saving interventions in the absence of a DNR order.

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