a nurse is assisting with mass casualty triage following an explosion at a local factory which of the following clients should the nurse identify as t
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Nursing Elites

ATI RN

ATI RN Exit Exam Quizlet

1. A healthcare provider is assisting with mass casualty triage following an explosion at a local factory. Which of the following clients should the healthcare provider identify as the priority?

Correct answer: C

Rationale: In a mass casualty situation, a client with hypovolemic shock should be the priority as they require immediate intervention to restore fluid volume and prevent further deterioration. Hypovolemic shock can lead to organ failure and death if not addressed promptly. While clients with other severe conditions like massive head trauma, full-thickness burns, or an open fracture also need urgent care, hypovolemic shock directly threatens the client's life due to inadequate circulating blood volume. Therefore, stabilizing the client with indications of hypovolemic shock takes precedence over others in this scenario.

2. What is the most appropriate nursing intervention for a patient experiencing hypoglycemia?

Correct answer: B

Rationale: The most appropriate nursing intervention for a patient experiencing hypoglycemia is to administer oral glucose. Oral glucose is usually sufficient for treating mild hypoglycemia and can be administered quickly and easily. Administering IV glucose (Choice A) is reserved for severe cases where the patient is unable to swallow or unconscious. Checking blood sugar in 15 minutes (Choice C) is important but providing glucose should come first. Providing a high-calorie snack (Choice D) may not be as rapidly effective as administering oral glucose in quickly raising blood sugar levels in a patient experiencing hypoglycemia.

3. A nurse is caring for a client who has pneumonia. Which of the following findings should the nurse report to the provider?

Correct answer: C

Rationale: In a client with pneumonia, crackles in the lung bases can indicate fluid accumulation, worsening of the condition, or development of complications such as pulmonary edema. This finding should be reported to the provider promptly for further evaluation and management. Choices A, B, and D are common in clients with pneumonia and may not necessarily require immediate reporting unless accompanied by other concerning symptoms or vital sign abnormalities.

4. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian for which of the following clients?

Correct answer: B

Rationale: The correct answer is B. A client with gout who plans to continue consuming anchovies should be referred to a dietitian for proper dietary education. Anchovies are high in purines, which can exacerbate gout symptoms. Choices A, C, and D do not require immediate dietitian referral as the statements made by these clients are appropriate actions regarding their prescribed medications (warfarin and spinach intake, spironolactone and potassium intake, and calcium carbonate and water intake, respectively).

5. A nurse is observing bonding between the client and her newborn. Which of the following actions by the client requires the nurse to intervene?

Correct answer: D

Rationale: The correct answer is D because viewing the newborn's actions as uncooperative may indicate the client is struggling to bond, requiring intervention. Choices A, B, and C do not raise concerns about the bonding process between the client and the newborn. Holding the newborn in an en face position is a positive interaction. Asking the father to change the newborn's diaper involves family participation in care. Requesting the nurse to take the newborn to the nursery so she can rest is a valid request for maternal self-care.

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