a nurse is planning care for a newly admitted adolescent with bacterial meningitis what intervention should the nurse include
Logo

Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment Form A

1. A nurse is planning care for a newly admitted adolescent with bacterial meningitis. What intervention should the nurse include?

Correct answer: A

Rationale: The correct intervention for a newly admitted adolescent with bacterial meningitis is to initiate droplet precautions. Bacterial meningitis is highly contagious, and droplet precautions are necessary to prevent the spread of infection. Assisting the client to a supine position (Choice B) is not directly related to managing bacterial meningitis. Performing a Glasgow Coma Scale every 24 hours (Choice C) may be important to assess the client's neurological status but is not the priority intervention in preventing the spread of infection. Recommending prophylactic acyclovir for the client's family (Choice D) is not a standard practice in the care of a patient with bacterial meningitis.

2. A nurse observes an assistive personnel (AP) providing care to a child who is in skeletal traction. Which of the following actions requires intervention?

Correct answer: C

Rationale: The correct answer is C. Placing weights on the child's bed can alter the traction, which must remain constant to be effective. This action requires immediate intervention to prevent harm. Providing a high-protein snack (Choice A) is appropriate for the child's nutritional needs. Assisting the child to reposition (Choice B) helps prevent complications such as pressure ulcers. Massaging pressure points (Choice D) can help promote circulation and prevent skin breakdown. However, altering the traction by placing weights on the bed can be detrimental to the child's condition and must be corrected promptly.

3. A nurse is providing teaching to a client who is at 34 weeks of gestation and is scheduled for a nonstress test. Which of the following statements should the nurse plan to make?

Correct answer: B

Rationale: The correct statement for the nurse to make is choice B, 'You should expect the test to take about 30 minutes.' The nonstress test is used to assess fetal well-being by monitoring fetal heart rate in response to movements. Choice A is incorrect because medications are not typically administered during a nonstress test. Choice C is incorrect as there is no need for the client to fast before the test. Choice D is incorrect because determining fetal lung maturity is usually done through other tests, not the nonstress test.

4. When teaching a client about the correct use of a cane, what should the nurse include?

Correct answer: B

Rationale: When using a cane, it should be held on the stronger side to provide optimal support and stability. This positioning allows the cane to bear weight effectively and helps in improving balance. Option A about ensuring the cane has a rubber cap is important for preventing slipping but is not directly related to the correct use of the cane. Option C, flexing the elbow slightly, is a general guideline and may vary depending on the individual's height and the type of cane being used. Option D suggesting the use of a quad cane for increased support is not necessary if a standard cane is sufficient for the client's needs.

5. A postpartum client's fundus is firm, 3 cm above the umbilicus, and displaced to the right. Which of the following interventions should the nurse take?

Correct answer: C

Rationale: The correct intervention for a postpartum client with a firm, displaced fundus is to assist the client to void then reassess the fundus. Displacement of the uterus to the right is often a sign of bladder distention, which can prevent the uterus from contracting properly and increase the risk of postpartum hemorrhage. By helping the client to void, the nurse can alleviate the bladder distention, allowing the uterus to contract effectively. Massaging the fundus (Choice A) may not address the underlying issue of bladder distention. Administering oxytocin (Choice B) is not indicated without assessing and addressing the cause of the displacement. Notifying the healthcare provider (Choice D) is premature before implementing initial nursing interventions to address the potential cause of the displaced fundus.

Similar Questions

A nurse is preparing to administer a dose of enoxaparin. Which of the following actions should the nurse take?
A client newly diagnosed with nephrotic syndrome is being taught by a nurse. Which statement indicates that the client understands the teaching?
A nurse is teaching a group of clients about the risk factors for osteoporosis. Which of the following should the nurse include as a risk factor for osteoporosis?
A nurse is caring for a client 4 hours postoperative following a thyroidectomy. The client reports fullness in the throat. What should the nurse assess for?
A nurse reviewing a patient’s care plan notes a goal of 'Patient will ambulate 50 feet three times in the hallway today.' Which domain of Bloom’s taxonomy is this goal in?

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