a nurse overhears two aps discussing a hospitalized patient while in the cafeteria what action should the nurse take
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN

1. While in the cafeteria, a nurse overhears two APs discussing a hospitalized patient. What action should the nurse take?

Correct answer: C

Rationale: The correct action for the nurse to take in this situation is to choose option C: 'Quietly tell the APs that this is not appropriate.' The nurse should immediately and discreetly address the situation, reminding the APs that discussing patient information in public areas violates confidentiality. Reporting the incident to the supervisor (option A) may be necessary if the behavior continues. Joining the conversation to intervene (option B) may escalate the situation and compromise patient confidentiality. Ignoring the conversation (option D) does not address the violation or prevent it from recurring.

2. A nurse is caring for a client prescribed levetiracetam. Which of the following should the nurse monitor?

Correct answer: C

Rationale: The correct answer is C: Serum creatinine. Levetiracetam requires monitoring of renal function, specifically serum creatinine levels, as it is primarily eliminated by the kidneys. Monitoring liver function (Choice A) is not necessary for levetiracetam. Blood glucose levels (Choice B) are typically not affected by levetiracetam. While monitoring blood pressure (Choice D) is important in general patient care, it is not specifically required for clients prescribed levetiracetam.

3. A nurse is caring for a client who has increased intracranial pressure (ICP). Which of the following interventions should the nurse implement?

Correct answer: C

Rationale: Keeping the client’s neck in a midline position is essential when caring for a client with increased intracranial pressure (ICP) as it helps promote optimal blood flow and reduces the risk of further increasing ICP. Placing pillows behind the client’s head (Choice A) may not be recommended as it could potentially increase ICP. Putting the client in a Sims' position (Choice B) and maintaining hip flexion at a 90° angle (Choice D) are not directly related to managing increased ICP and are not the priority interventions in this situation.

4. A nurse is assisting with mass casualty triage following an explosion at a local factory. Which of the following clients should the nurse identify as the priority?

Correct answer: C

Rationale: In a mass casualty situation, the nurse should prioritize the client with indications of hypovolemic shock. Hypovolemic shock is an immediate life-threatening condition resulting from severe blood loss, which can lead to organ failure and death. Prompt identification and treatment of hypovolemic shock are crucial to prevent further deterioration. While clients with massive head trauma, full-thickness burns, and open fractures require urgent care, hypovolemic shock takes precedence due to its rapid progression to a critical state.

5. A nurse is teaching a group of assistive personnel (AP) about caring for clients with Alzheimer's disease. Which of the following information should the nurse include in the teaching?

Correct answer: D

Rationale: The correct answer is D because clients with Alzheimer's disease can be prone to wandering and getting lost. Providing supervision can help prevent injuries and ensure their safety. Choices A, B, and C are incorrect because explaining procedures clearly, encouraging varied activities, and using simple communication are important but not specifically focused on the safety aspect of preventing clients from getting lost or injured.

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