a nurse is teaching a patient how to prevent falls at home which instruction is most appropriate
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment A

1. A healthcare professional is teaching a patient how to prevent falls at home. Which instruction is most appropriate?

Correct answer: B

Rationale: The most appropriate instruction to prevent falls at home is to remove loose rugs and install grab bars in high-risk areas like the bathroom. This helps eliminate tripping hazards and provides stability for the patient. Keeping the living space well-lit (Choice A) is important but may not directly address fall prevention. Using furniture for support (Choice C) can lead to accidents if the furniture is not stable. Wearing socks without shoes (Choice D) increases the risk of slipping rather than preventing falls.

2. While assessing a migrant farm worker in a mobile health clinic, which of the following findings should the nurse identify as the priority?

Correct answer: D

Rationale: The correct answer is D because muscle twitching and a rash could indicate pesticide poisoning, a serious condition that requires immediate attention in a migrant farm worker. Option A is not the priority as it could be musculoskeletal in nature and managed after addressing urgent issues. Option B, absence of a dental health provider, though important for overall health, is not an immediate priority. Option C, living with 25 other migrant workers, raises concerns about living conditions but does not present an immediate health threat compared to potential pesticide poisoning.

3. A client has a new prescription for guaifenesin. What information regarding the action of guaifenesin should the nurse include in the teaching?

Correct answer: C

Rationale: The correct answer is C: 'Increases cough production.' Guaifenesin is an expectorant that works by increasing cough production to help clear secretions from the airways. Option A is incorrect because guaifenesin does not decrease mucus production but rather helps to make the mucus easier to cough up. Option B is incorrect as guaifenesin does not reduce nasal congestion. Option D is incorrect because guaifenesin does not have any effect on reducing fever.

4. The nurse is observing the way a patient walks. What aspect is the nurse assessing?

Correct answer: B

Rationale: The correct answer is B: Gait. Gait refers to the manner in which a person walks, including aspects such as stride length, step width, and walking speed. When a nurse observes a patient's gait, they are assessing their mobility and looking for any abnormalities or issues in their walking pattern. Choice A, body alignment, focuses more on the posture and position of the body rather than the actual walking pattern. Choice C, activity tolerance, relates to the ability to withstand physical activity without experiencing excessive fatigue. Choice D, range of motion, pertains to the extent of movement at a joint and is not directly related to observing the way a patient walks.

5. A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel?

Correct answer: D

Rationale: The correct answer is applying the restraint (Choice D). Nursing assistive personnel can be delegated the task of applying restraints under the supervision and direction of a nurse. Determining the need for restraints (Choice A) and obtaining an order for a restraint (Choice B) involve clinical judgment and assessment, which are responsibilities of the nurse. Assessing the patient's orientation (Choice C) also requires a level of assessment that should be performed by a nurse.

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