what is the most important nursing action when a patient experiences a fall
Logo

Nursing Elites

ATI RN

ATI RN Exit Exam

1. What is the most important nursing action when a patient experiences a fall?

Correct answer: A

Rationale: The most important nursing action when a patient experiences a fall is to assess the patient for injuries. This is critical to identify any potential harm or underlying issues that may require immediate attention. Calling for help and notifying the healthcare provider are important steps, but assessing the patient's condition takes precedence to ensure prompt and appropriate care. Documenting the fall is also necessary but should follow the initial assessment and care provided to the patient.

2. A client who wears glasses is under the care of a nurse. Which of the following actions should the nurse take?

Correct answer: A

Rationale: The correct action for the nurse to take is to store the glasses in a labeled case. This ensures the safety of the glasses and helps in their proper identification when needed. Cleaning the glasses with hot water (Choice B) can damage them, and using a paper towel (Choice C) can scratch the lenses. Storing the glasses on the bedside table (Choice D) can lead to misplacement or damage. Therefore, the most appropriate action is to store the glasses in a labeled case.

3. A nurse is caring for a client who has a new prescription for spironolactone. Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the medication?

Correct answer: C

Rationale: Corrected Rationale: Spironolactone is a potassium-sparing diuretic, so serum potassium should be monitored to evaluate its effectiveness. Monitoring serum potassium levels is crucial because spironolactone can cause hyperkalemia as a side effect. Serum sodium, serum calcium, and serum glucose levels are not directly affected by spironolactone and would not provide an accurate assessment of the medication's effectiveness.

4. A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the priority for the nurse to report?

Correct answer: D

Rationale: Stridor is a high-pitched sound that indicates airway obstruction and is the priority finding to report following a thyroidectomy. In this situation, airway compromise is a critical concern that requires immediate intervention to ensure adequate oxygenation. While calcium level (Choice A) and serum sodium level (Choice B) are important assessments post-thyroidectomy, they do not represent an immediate threat to the client's airway. A respiratory rate of 18/min (Choice C) falls within the normal range and does not indicate an immediate risk to the client's airway compared to the presence of stridor.

5. A client has a new prescription for metformin. Which of the following client statements indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B. Metformin should be taken with a full glass of water in the morning to improve absorption and prevent gastrointestinal upset. Choice A is incorrect because metformin is not typically taken at bedtime. Choice C is unrelated to metformin therapy. Choice D is incorrect because metformin is actually better absorbed when taken with or after meals.

Similar Questions

A nurse is caring for a client who is in the orientation phase of the therapeutic relationship. Which statement should the nurse make during this phase?
When discussing clients designating a health care proxy in situations requiring a durable power of attorney for health care (DPAHC), what information should the charge nurse include?
A nurse is assessing a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings should the nurse report to the provider?
How should bleeding in a patient on warfarin be monitored?
A client scheduled for a thoracentesis requires assistance from a nurse. Which of the following actions should the nurse take?

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