a nurse is caring for a client who is experiencing acute alcohol withdrawal which of the following actions should the nurse take
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ATI RN

ATI RN Exit Exam Quizlet

1. A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following actions should the nurse take?

Correct answer: C

Rationale: The correct action the nurse should take when caring for a client experiencing acute alcohol withdrawal is to administer lorazepam as prescribed. Lorazepam is a benzodiazepine used to prevent seizures and manage agitation in clients undergoing alcohol withdrawal. Administering haloperidol (Choice A) is not recommended in alcohol withdrawal as it may lower the seizure threshold. Keeping the client in a supine position (Choice B) is not specifically indicated in managing alcohol withdrawal. Encouraging the client to drink fluids with meals (Choice D) is important for hydration but does not address the acute symptoms of alcohol withdrawal.

2. A nurse overhears two assistive personnel (AP) discussing a client in an elevator. What action should the nurse take?

Correct answer: D

Rationale: The correct action for the nurse to take in this situation is to report the incident to the AP's charge nurse. This is important because discussing a client's information violates confidentiality policies. Contacting the client's family (Choice A) is not appropriate as it may breach confidentiality further. Notifying the client's provider (Choice B) is not the initial action to take in this situation, as addressing it within the facility should come first. Filing a complaint with the facility's ethics committee (Choice C) is not the immediate step and might not directly address the issue at hand.

3. A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

Correct answer: C

Rationale: The correct answer is C. Monitoring blood glucose levels before meals and at bedtime is crucial for managing type 2 diabetes mellitus. Option A is incorrect because limiting protein intake is not a primary focus for diabetes management. Option B is unrelated to diabetes management and focuses on pain relief. Option D mentions reducing carbohydrate intake, which is a common dietary recommendation for managing blood sugar levels, but it is not as specific as monitoring blood glucose levels at key times.

4. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take first?

Correct answer: A

Rationale: The correct first action for the nurse to take when preparing to administer a unit of packed RBCs is to check the client's identification band. This step is crucial to ensure that the correct blood is administered to the right client, preventing any errors or adverse reactions. Verifying the provider's prescription, priming the IV tubing, and obtaining the client's vital signs are important steps in the process but should follow the initial identification check to prioritize patient safety.

5. A healthcare professional is caring for a client who has a prescription for enoxaparin. Which of the following laboratory tests should the healthcare professional review before administering the medication?

Correct answer: D

Rationale: Corrected Rationale: Before administering enoxaparin, it is essential to review potassium levels to monitor for potential imbalances. Enoxaparin, a type of anticoagulant, does not directly affect PT, INR, or platelet count. Monitoring potassium levels is crucial to ensure the safety and effectiveness of the medication. PT and INR are typically used to monitor warfarin therapy, while platelet count is essential for assessing clotting function but is not directly related to enoxaparin administration.

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