a nurse is caring for a client who has dementia which of the following interventions should the nurse take to minimize the risk for injury for this cl
Logo

Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2023 with NGN

1. A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury for this client?

Correct answer: A

Rationale: The correct answer is A: Using a bed exit alarm system. A bed exit alarm alerts staff when a client with dementia attempts to leave the bed, reducing the risk of falls. Choice B is incorrect because raising all four side rails can lead to restraint-related injuries and is not recommended. Choice C is incorrect as applying wrist restraints should be avoided due to the risk of injury and decreased mobility. Choice D is incorrect as dimming the lights in the client's room does not directly address the risk of injury associated with dementia.

2. Which of the following findings indicates a need for immediate attention in a client diagnosed with delirium?

Correct answer: C

Rationale: The correct answer is C: Irritability and agitation that worsen throughout the day. These symptoms are concerning in a client diagnosed with delirium as they may indicate an exacerbation of the condition or an underlying cause that requires immediate attention. Option A describes symptoms that resolve with rest, which may not be as urgent. Option B provides a normal blood pressure reading, which is not typically associated with immediate attention in delirium cases. Option D describes mild confusion during specific hours, which may not be as critical as worsening symptoms throughout the day.

3. A nurse is caring for a client receiving IV fluids. Which of the following should the nurse do upon noticing phlebitis at the IV site?

Correct answer: C

Rationale: Upon noticing phlebitis at the IV site, the nurse should remove the IV catheter and restart it in another location. Phlebitis is inflammation of the vein, and leaving the IV catheter in place can lead to further complications such as infection. Applying a cold compress (Choice A) may provide temporary relief but does not address the underlying issue. Notifying the provider immediately (Choice B) is important, but the immediate action to prevent complications is to remove the IV catheter. Monitoring the site for signs of infection (Choice D) is necessary, but the priority action is to remove and reinsert the IV catheter to prevent worsening of the phlebitis.

4. When managing a physically assaultive client, the nurse's INITIAL priority is to

Correct answer: C

Rationale: When dealing with a physically assaultive client, the initial priority is to focus on restoring the client's self-control and preventing further escalation. Restricting the client to the room (choice A) may escalate the situation and is not the initial priority. Placing the client under one-to-one supervision (choice B) is important but comes after ensuring the client's self-control. Clearing the immediate area of other clients (choice D) is essential for safety but is not the initial priority when compared to restoring the client's self-control.

5. A client has developed phlebitis at the IV site. What should the nurse do immediately?

Correct answer: B

Rationale: When a client develops phlebitis at the IV site, the immediate action the nurse should take is to discontinue the IV and notify the provider. Phlebitis is inflammation of the vein, and if left untreated, it can lead to serious complications such as infection, thrombosis, or sepsis. Removing the IV line helps prevent further irritation and infection. Applying a warm compress (Choice A) may provide some relief but does not address the root cause. Monitoring for signs of infection (Choice C) is important but not the immediate action needed to address phlebitis. Administering an anti-inflammatory medication (Choice D) may be prescribed by the provider but is not the first step in managing phlebitis.

Similar Questions

Which of the following interventions is most appropriate for a client with a pressure ulcer who has a low albumin level?
What are the risk factors for developing hypertension?
A healthcare provider is reviewing the medical record of a client who is scheduled for surgery. Which of the following findings should the provider report?
What is the best dietary recommendation for a patient with chronic kidney disease?
What are the key interventions for managing pneumonia?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses