a nurse is caring for a client who has vision loss which of the following actions should the nurse not take
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Nursing Elites

ATI RN

ATI Fundamentals Proctored Exam 2023

1. A client with vision loss is under the care of a nurse. Which of the following actions should the nurse AVOID?

Correct answer: C

Rationale: Approaching a client with vision loss from the side can startle them and may lead to accidents or discomfort. It is important to approach them from the front so they are aware of your presence. Keeping objects in the same place aids in familiarity and reduces the risk of falls. High-wattage lighting enhances visibility for the client. Allowing extra time for tasks accommodates the client's potential slower pace and ensures they can perform tasks safely.

2. A client is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make?

Correct answer: B

Rationale: Dehydration can lead to an imbalance in electrolytes and cause uterine irritability, potentially leading to preterm contractions. It is essential for the nurse to educate the client on the importance of adequate hydration to reduce the risk of preterm labor. The statement 'Dehydration can increase the risk of preterm labor' directly addresses the client's condition and provides relevant information for their understanding and management of the situation.

3. When caring for a client who speaks a language different from their own, what action should the nurse take?

Correct answer: D

Rationale: When caring for a client who speaks a different language, it is essential for the nurse to review the facility policy about the use of an interpreter. Using a professional interpreter ensures accurate communication and protects the client's confidentiality. Requesting an interpreter of a specific sex or relying on family members or friends can lead to miscommunication or breaches of confidentiality. Directing attention towards the interpreter helps facilitate communication but does not address the need for a professional interpreter as per facility policy.

4. When caring for a client who is to have a line placed for hemodynamic monitoring, which statement by the newly licensed nurse indicates effectiveness of the teaching?

Correct answer: D

Rationale: After a line is placed for hemodynamic monitoring, it is crucial to confirm its correct placement. The definitive way to verify the placement is through a chest x-ray. This ensures that the line is appropriately positioned without complications. Options A, B, and C do not address the essential step of confirming the line's placement, making them incorrect choices.

5. Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery?

Correct answer: C

Rationale: Immobility, diaphoresis, and avoidance of deep breathing or coughing are common signs of pain.

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