a nurse receives a report from an assistive personnel that a clients bp is 16095 what should the nurse do first
Logo

Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. A nurse receives a report from an assistive personnel that a client's BP is 160/95. What should the nurse do first?

Correct answer: C

Rationale: The correct first action for the nurse in this scenario is to recheck the blood pressure. This step is crucial to confirm the accuracy of the initial reading. Administering antihypertensive medication without verifying the blood pressure could lead to inappropriate treatment. Notifying the healthcare provider can be done after ensuring the accuracy of the reading. Simply documenting the blood pressure without validation may result in acting on potentially incorrect information. Therefore, the priority is to recheck the blood pressure.

2. When providing discharge teaching to a client prescribed home oxygen therapy, what information should the nurse include?

Correct answer: B

Rationale: The correct answer is B: 'Avoid smoking and open flames near oxygen.' This information is crucial to prevent fire hazards when using home oxygen therapy. Smoking and open flames near oxygen can lead to serious accidents. Choice A is incorrect because increasing the oxygen flow rate during activity without healthcare provider guidance can be dangerous. Choice C is incorrect as oxygen tanks should be stored in a well-ventilated area, not necessarily warm and dry. Choice D is incorrect as oxygen should not be turned off and on by the client, as it can affect the therapy's effectiveness and cause safety issues.

3. A healthcare professional is reviewing a client's medical history and identifies an increased risk for infections. What risk factor should the healthcare professional include?

Correct answer: D

Rationale: The correct answer is D: Chronic conditions. Chronic conditions, such as diabetes or immune suppression, can compromise the immune system, making individuals more susceptible to infections. Frequent handwashing (Choice A) is actually a protective measure against infections. Increased mobility (Choice B) and high blood pressure (Choice C) are not directly associated with an increased risk for infections.

4. A nurse is assessing a client who reports pain at the site of an indwelling urinary catheter. What is the nurse's first action?

Correct answer: B

Rationale: When a client reports pain at the site of an indwelling urinary catheter, the nurse's first action should be to notify the provider. This is important to ensure timely assessment and intervention by the healthcare provider. Irrigating the catheter with normal saline or administering antibiotics should not be done without provider's orders as it may mask symptoms or lead to inappropriate treatment. Assessing for signs of infection is important but should come after notifying the provider, who can guide further assessment and treatment.

5. A client with diabetes mellitus is being taught about foot care. What statement by the client indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B. Wearing slippers or shoes at all times when out of bed is crucial for clients with diabetes mellitus to protect their feet from injury. Option A is incorrect as soaking feet in warm water can lead to dry skin, making it more susceptible to injuries. Option C is incorrect as applying lotion between the toes can create a moist environment, increasing the risk of fungal infections. Option D is incorrect as cutting toenails straight across is a good practice but is not directly related to preventing foot injuries in clients with diabetes.

Similar Questions

A client with diabetes mellitus has a foot ulcer. What is an appropriate intervention to promote wound healing?
A nurse is assessing a client who reports a burning sensation at the site of a peripheral IV. The site is red and warm. What should the nurse do?
A client with diabetes mellitus is being taught about foot care by a nurse. What statement indicates understanding?
A client with a new diagnosis of diabetes mellitus is being taught about foot care. What instruction should the nurse include?
When teaching about safety risks for adolescents, what should the nurse emphasize?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses