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

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?

A. Administer haloperidol as prescribed.
B. Keep the client in a supine position.
C. Administer lorazepam as prescribed.
D. Encourage the client to drink fluids with meals.

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 is providing dietary teaching to a client who has chronic kidney disease. Which of the following food choices by the client indicates an understanding of the teaching?

A. Peanut butter and jelly sandwich
B. Grilled chicken and rice
C. Tomato soup with saltine crackers
D. Baked fish and steamed vegetables

Correct answer: D

Rationale: The correct answer is D, baked fish and steamed vegetables. These food choices are low in potassium and phosphorus, which is important for clients with chronic kidney disease to manage their condition effectively. Grilled chicken and rice (choice B) may be high in phosphorus, tomato soup with saltine crackers (choice C) is high in sodium, and a peanut butter and jelly sandwich (choice A) contains high levels of potassium, all of which are not ideal choices for individuals with chronic kidney disease.

3. A nurse in a mental health facility receives a change of shift report on four clients. Which of the following clients should the nurse plan to assess first?

A. Client placed in restraints due to aggressive behavior
B. A new client with a history of 4.5 kg weight loss in the past two months
C. Client receiving PRN dose of haloperidol 2 hours ago for anxiety
D. Client receiving first ECT treatment today

Correct answer: A

Rationale: The nurse should plan to assess the client placed in restraints due to aggressive behavior first. Clients in restraints require immediate attention and frequent monitoring for safety. While weight loss, medication administration, and ECT treatment are important, the client in restraints is in a critical situation that requires immediate assessment and intervention.

4. How should a healthcare provider monitor a patient with fluid overload?

A. Monitor daily weight
B. Check for edema
C. Monitor input and output
D. Monitor blood pressure

Correct answer: A

Rationale: Monitoring daily weight is crucial in assessing fluid retention accurately in a patient with fluid overload. Changes in weight can indicate fluid accumulation or loss, providing valuable information for healthcare providers. Checking for edema (choice B) is important but may not always accurately reflect total body fluid status. Monitoring input and output (choice C) and blood pressure (choice D) are also essential aspects of patient assessment, but they may not directly reflect the extent of fluid overload as effectively as monitoring daily weight.

5. What is the best intervention for a patient with constipation?

A. Administer a stool softener
B. Encourage fluid intake
C. Provide a high-fiber diet
D. Administer a laxative

Correct answer: B

Rationale: Encouraging fluid intake is the best intervention for a patient with constipation. Fluids help soften stools, making them easier to pass. While stool softeners and laxatives can also help with constipation, they are more of a short-term solution and may not address the root cause. A high-fiber diet is beneficial for preventing constipation in the long run, but in the immediate situation of constipation, fluid intake is key.