a patient is admitted with suspected pneumonia what is the nurses priority assessment
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN

1. A patient is admitted with suspected pneumonia. What is the nurse's priority assessment?

Correct answer: B

Rationale: The correct answer is to assess the patient's oxygen saturation. In suspected pneumonia, ensuring adequate oxygenation is critical to monitor respiratory function. Auscultating lung sounds is important but assessing oxygen saturation takes precedence as it directly reflects the patient's oxygen levels. Monitoring white blood cell count is more related to infection assessment rather than immediate respiratory status. Checking skin integrity is essential for overall patient care but is not the priority in a patient with suspected pneumonia.

2. A nurse is preparing to administer medications to a client via a nasogastric (NG) tube. What should the nurse do first?

Correct answer: B

Rationale: The correct answer is B: 'Flush the NG tube before and after each medication.' Flushing the NG tube is essential to ensure that the medication passes through smoothly without any obstruction. It helps prevent clogging of the tube and ensures that the full dose of the medication reaches the patient. Options A, C, and D are incorrect because crushing all medications at once, administering only liquid forms of medications, and skipping tube flushing entirely can lead to complications such as tube blockages, incomplete medication administration, and potential harm to the client.

3. What is the most appropriate action for a healthcare professional to take when a medication error occurs?

Correct answer: B

Rationale: When a medication error occurs, the most appropriate action for a healthcare professional is to report the error to the healthcare provider immediately. This is crucial for ensuring prompt corrective action to mitigate any potential harm to the patient. Documenting the error is important but should come after reporting it to the relevant authorities. Apologizing to the patient is important for maintaining trust and communication but should not take precedence over reporting and addressing the error. Continuing to administer the medication without addressing the error is unsafe and goes against patient safety protocols.

4. A nurse is planning care for a client who has dehydration and is receiving a continuous IV infusion of 0.9% sodium chloride. Which of the following interventions should the nurse include in the plan of care?

Correct answer: D

Rationale: Offering the client 240 ml (8 oz) of oral fluids every 4 hours is essential to maintain hydration in a client with dehydration who is receiving continuous IV infusion. This intervention helps ensure an adequate fluid balance. Monitoring the client's intake and output every 6 hours is necessary to assess hydration status and response to treatment. Administering furosemide to the client, choice B, is contraindicated in dehydration as it can further deplete fluid volume. Checking the IV infusion every 8 hours, as in choice C, is important but not as critical as ensuring oral fluid intake to promote hydration.

5. In a disaster where a building has collapsed, which victim should a nurse attend to first?

Correct answer: B

Rationale: In a disaster situation like a building collapse, the nurse should attend to the victim with a partial amputation of a leg who is bleeding profusely first. This victim is at immediate risk of severe blood loss, which can be life-threatening. It is crucial to address life-threatening injuries like severe bleeding before attending to other less urgent cases. The victim with the amputation requires immediate intervention to control bleeding and stabilize their condition. Victims who are already deceased or have less urgent injuries can be attended to after addressing the critical cases.

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