how should a nurse respond to a patient who is experiencing confusion after surgery
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Nursing Elites

ATI RN

ATI RN Exit Exam

1. How should a healthcare professional respond to a patient who is experiencing confusion after surgery?

Correct answer: A

Rationale: Administering oxygen is the most appropriate initial response to a patient experiencing confusion after surgery. Confusion can be a sign of hypoxia, which is inadequate oxygen supply to the brain. Administering oxygen helps ensure that the patient is getting enough oxygen, addressing a potential cause of the confusion. Repositioning the patient, encouraging deep breathing exercises, or performing a neurological exam may be necessary depending on the situation, but addressing potential hypoxia should be the priority in a confused post-operative patient.

2. What is the first action to take for a patient experiencing a seizure?

Correct answer: B

Rationale: The first action a nurse should take for a patient experiencing a seizure is to protect the patient's head. This is crucial to prevent head injuries during the seizure. Administering anticonvulsant medication may be necessary but is not the first action. Inserting an oral airway may cause injury as the patient may bite down during a seizure. Restraint is not recommended as it can lead to further harm.

3. A nurse is caring for a client who has Raynaud's disease. Which of the following actions should the nurse take?

Correct answer: A

Rationale: Corrected Rationale: Providing information about stress management is essential when caring for a client with Raynaud's disease because stress can trigger episodes. Stress management techniques can help the client avoid triggers and reduce the frequency of episodes. Choice B is incorrect because maintaining a warm temperature, rather than a cool one, helps prevent vasoconstriction and can be beneficial for clients with Raynaud's disease. Choice C is incorrect because epinephrine is not a standard treatment for Raynaud's disease; it is more commonly used for severe allergic reactions. Choice D is incorrect because glucocorticoid steroids are not typically used in the management of Raynaud's disease.

4. A nurse is providing discharge teaching to a client who has a new prescription for lithium. Which of the following instructions should the nurse include?

Correct answer: C

Rationale: The correct instruction for a client prescribed lithium is to drink at least 2 liters of water each day. This is important to prevent dehydration and reduce the risk of lithium toxicity. Option A is incorrect because lithium is usually taken with food to minimize gastrointestinal side effects. Option B is unrelated to lithium and is more applicable to clients taking MAOIs. Option D is incorrect as lithium is typically taken in divided doses throughout the day to maintain therapeutic levels.

5. A client has a new prescription for levothyroxine. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct instruction when taking levothyroxine is to take it on an empty stomach. This enhances absorption and ensures the medication's effectiveness. Taking it with food or other substances, such as milk or antacids, can interfere with its absorption. Therefore, choices A, C, and D are incorrect.

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