what is the appropriate action for a nurse to take when a patient has a high fever and is disoriented
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Nursing Elites

ATI RN

ATI RN Comprehensive Exit Exam

1. What is the appropriate action for a healthcare provider to take when a patient has a high fever and is disoriented?

Correct answer: C

Rationale: Administering fluids is the appropriate action for a healthcare provider to take when a patient has a high fever and is disoriented. Dehydration can worsen confusion and other symptoms in such a situation. Administering acetaminophen or cooling the patient with cold compresses may help reduce the fever but does not address the underlying issue. Administering antibiotics is not indicated for a high fever and disorientation without knowing the cause.

2. A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take?

Correct answer: B

Rationale: The correct answer is to wear gloves to apply the patch to the client's skin. This action ensures that the nurse does not absorb any medication through their own skin, promoting safety. Choice A is incorrect because shaving is not necessary and could irritate the skin. Choice C is incorrect because transdermal patches should be applied immediately after removal from the protective pouch to maintain their efficacy. Choice D is incorrect because used patches should be folded and discarded safely according to facility protocols.

3. A nurse is planning care for a client who has pneumonia. Which of the following interventions should the nurse include to promote airway clearance?

Correct answer: A

Rationale: Encouraging the client to increase fluid intake is essential to promote airway clearance in pneumonia. Adequate hydration helps to thin respiratory secretions, making them easier to expectorate. Suctioning every 2 hours may be too frequent and can lead to airway trauma and irritation. Chest physiotherapy is not typically indicated for pneumonia unless there are specific complications. Administering oxygen via nasal cannula may be necessary to maintain oxygen saturation but does not directly promote airway clearance.

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

Correct answer: C

Rationale: The correct answer is C: 'Notify your provider if you experience visual disturbances.' Visual disturbances can indicate digoxin toxicity, so it is essential for clients taking digoxin to report any changes in vision to their healthcare provider. Option A is incorrect because the timing of digoxin administration is crucial, usually in the morning. Option B is inaccurate because digoxin should not be taken with milk as it can affect its absorption. Option D is not directly associated with digoxin use and should not be the priority instruction for a client on this medication.

5. What is the best intervention for a patient with respiratory distress?

Correct answer: A

Rationale: The correct answer is to administer oxygen. In respiratory distress, the priority intervention is to improve oxygenation. Administering oxygen helps increase the oxygen levels in the blood, supporting respiratory function. While bronchodilators may be used in specific respiratory conditions like asthma or COPD, they are not the primary intervention for respiratory distress. IV fluids are not indicated as the initial treatment for respiratory distress unless there is an underlying cause such as dehydration. Corticosteroids may be used in certain respiratory conditions to reduce inflammation, but they are not the first-line intervention for acute respiratory distress.

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