a nurse is caring for a client who is vomiting which of the following actions should the nurse take first
Logo

Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN

1. A client is vomiting, and a nurse is providing care. Which of the following actions should the nurse take first?

Correct answer: C

Rationale: Preventing aspiration is the priority when caring for a client who is vomiting to reduce the risk of pneumonia or other respiratory complications. Aspiration can occur when vomitus enters the airway, leading to respiratory distress. Ensuring the airway is protected during vomiting episodes is essential. Administering an antiemetic (Choice A) can be considered after addressing the immediate risk of aspiration. Notifying housekeeping (Choice B) and providing an emesis basin (Choice D) are important but are secondary to preventing aspiration, which is crucial for the client's safety and well-being.

2. The nurse is preparing a care plan for a patient who is immobile. Which psychosocial aspect will the nurse assess for?

Correct answer: C

Rationale: When a patient is immobile, the nurse should assess for psychosocial aspects, including a loss of hope and increased risk of depression. While issues like weight loss (choice A), loss of bone mass (choice B), and loss of strength (choice D) can also occur due to immobility, the primary concern in this scenario is the patient's mental and emotional well-being, making 'Loss of hope' the correct answer.

3. A client with asthma is taking fluticasone. The nurse should monitor the client for which of the following adverse effects?

Correct answer: B

Rationale: Correct. Fluticasone, a corticosteroid medication commonly used to manage asthma, can lead to oral candidiasis due to its immunosuppressive effects. This fungal infection can manifest as white patches in the mouth and throat. Monitoring for signs of oral candidiasis is essential to initiate appropriate treatment. Polyuria (excessive urination) is not a common adverse effect of fluticasone. Hypertension and hypoglycemia are also not typically associated with this medication, making them incorrect choices.

4. A healthcare provider is providing teaching for a patient with a prescription for oral metronidazole, what is the priority teaching point?

Correct answer: B

Rationale: The correct answer is to 'Report a rash.' Metronidazole can cause severe adverse reactions like Stevens-Johnson syndrome, a life-threatening rash. It is crucial to educate the patient to report any rash immediately to prevent serious complications. Choices A, C, and D are incorrect because while they may be relevant to consider during metronidazole therapy, they are not the priority teaching point. Headaches can occur but are not as serious as a rash; avoiding sunlight is more related to doxycycline, not metronidazole; and taking with meals is a general instruction for some medications but not the priority teaching point for metronidazole.

5. A nurse observes a colleague not using proper hand hygiene. What should the nurse do first?

Correct answer: D

Rationale: The correct action for the nurse to take first is to report the behavior to the supervisor. Proper hand hygiene is essential in preventing the spread of infections in healthcare settings. By reporting the observed behavior to the supervisor, the nurse is prioritizing patient safety and promoting a culture of accountability. Ignoring the behavior (Choice A) can put patients at risk, discussing it with other colleagues (Choice B) may not address the issue effectively, and confronting the colleague directly (Choice C) might not be the most appropriate initial step and could lead to conflicts rather than a constructive resolution.

Similar Questions

What is the primary focus of secondary prevention in community mental health care?
A healthcare professional is giving a change-of-shift report about a client admitted earlier that day with pneumonia. Which of the following pieces of information is the priority for the healthcare professional to provide?
A healthcare professional suspects a colleague of diverting narcotics. What is the first step the healthcare professional should take?
A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?
A client has a new prescription for guaifenesin. What information regarding the action of guaifenesin should the nurse include in the teaching?

Access More Features

ATI RN Basic
$69.99/ 30 days

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

ATI RN Premium
$149.99/ 90 days

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

Other Courses