a client experiences difficulty breathing after the change of shift the nurse on duty discovers that the ivfs were infusing at a rate 10 times the cal
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Nursing Elites

ATI RN

ATI Leadership

1. After correcting the IVF infusion rate, what should be the next step in the client's care?

Correct answer: C

Rationale: The correct next step in the client's care after correcting the IVF infusion rate is to complete an incident report. This report is crucial for documenting the event, identifying the root cause of the error, and implementing measures to prevent similar incidents in the future. Notifying the family, disciplining the previous nurse, and obtaining legal consultation are not immediate priorities in this situation. Family notification may be necessary later but ensuring patient safety and proper documentation come first. Disciplining the previous nurse should be handled through the appropriate professional channels, not as an immediate response to the incident. Legal consultation may be needed in some cases but is not the initial step required after correcting the error and ensuring the client's safety.

2. Which action by a patient indicates that the home health nurse’s teaching about glargine and regular insulin has been successful?

Correct answer: D

Rationale:

3. A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?

Correct answer: B

Rationale: The correct answer is B: 'Distended neck veins.' Distended neck veins are a sign of fluid volume excess, indicating an overload of fluids in the body. This can be caused by excessive fluid administration. Hypotension (choice A) is more commonly associated with fluid volume deficit. Slow capillary refill (choice C) and a weak, thready pulse (choice D) are also signs of decreased fluid volume, not fluid volume excess.

4. After the nurse has finished teaching a patient who has a new prescription for exenatide (Byetta), which patient statement indicates that the teaching has been effective?

Correct answer: C

Rationale:

5. Horizontal violence may be observed among staff interactions and causes stress among staff. To minimize stress associated with such interactions, nurses can: (Select all that apply.)

Correct answer: B

Rationale: To minimize stress associated with horizontal violence among staff interactions, nurses should take control of the situation by being assertive. Being assertive allows nurses to address the issues causing stress in a constructive and professional manner. Encouraging venting without addressing the underlying problems may not resolve the situation effectively. Ignoring staff who are volatile can escalate the issue further, and avoiding interactions with angry staff does not address the root cause of the problem. Therefore, being assertive and addressing the situation directly is the most effective approach to minimize stress and promote a healthy work environment.

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