what is the appropriate intervention when a patient experiences a fall
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Nursing Elites

ATI RN

ATI RN Exit Exam 2023

1. What is the appropriate intervention when a patient experiences a fall?

Correct answer: A

Rationale: The appropriate intervention when a patient experiences a fall is to assess for injuries. This immediate action helps in identifying any harm or complications resulting from the fall, allowing for timely intervention. Calling for help may be necessary after assessing the injuries, but the priority is to evaluate the patient's condition. Documenting the fall is important for record-keeping purposes but should come after ensuring the patient's safety. Notifying the healthcare provider can be done once the assessment has been completed and any necessary initial interventions have been initiated.

2. A healthcare provider is preparing to administer an intramuscular injection to a client. Which of the following actions should the provider take?

Correct answer: A

Rationale: Correct answer: When administering an intramuscular injection, the needle should be inserted at a 90-degree angle to ensure proper delivery of the medication into the muscle tissue. Option B is incorrect because a 45-degree angle is typically used for subcutaneous injections, not intramuscular. Option C is incorrect as aspiration is not recommended for intramuscular injections. Option D is incorrect as massaging the site after an intramuscular injection can cause tissue damage or interfere with the absorption of the medication.

3. A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make?

Correct answer: B

Rationale: The correct statement the nurse should make is that dehydration can increase the risk of preterm labor. Dehydration reduces amniotic fluid and uterine blood flow, potentially leading to preterm contractions. Choice A is incorrect because dehydration is not treated with calcium supplements but rather with adequate fluid intake. Choice C is incorrect as dehydration does not directly increase gastroesophageal reflux. Choice D is incorrect as dehydration is not caused by decreased hemoglobin and hematocrit levels but rather by insufficient fluid intake or excessive fluid loss.

4. While caring for a newborn under phototherapy lights, which of the following is an appropriate nursing action?

Correct answer: A

Rationale: The correct answer is to ensure the eye shield is covering the eyes. Protecting the newborn's eyes from exposure to direct light is crucial during phototherapy to prevent potential eye damage. Applying lotion to the exposed skin (choice B) is not recommended as it can interfere with the effectiveness of the phototherapy. Offering glucose water between feedings (choice C) is not necessary and may not be suitable for a newborn undergoing treatment. Discontinuing breastfeeding during treatment (choice D) is not recommended as breast milk provides essential nutrients and hydration for the newborn, and breastfeeding should continue unless contraindicated by a specific medical condition.

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

Correct answer: D

Rationale: The correct answer is D because taking metformin with food helps reduce gastrointestinal discomfort, a common side effect of the medication. Choice A is incorrect as metformin is usually taken with meals to minimize side effects. Choice B is incorrect because metformin does not typically cause urine discoloration. Choice C is incorrect as metformin is associated with weight loss or weight neutrality rather than weight gain.

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