a nurse is providing teaching to a client who has a new prescription for guaifenesin what info regarding the action of guaifenesin should the nurse in
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B

1. A client has a new prescription for guaifenesin. What information regarding the action of guaifenesin should the nurse include in the teaching?

Correct answer: C

Rationale: The correct answer is C: 'Increases cough production.' Guaifenesin is an expectorant that works by increasing cough production to help clear secretions from the airways. Option A is incorrect because guaifenesin does not decrease mucus production but rather helps to make the mucus easier to cough up. Option B is incorrect as guaifenesin does not reduce nasal congestion. Option D is incorrect because guaifenesin does not have any effect on reducing fever.

2. Which nursing action will most likely increase a patient's risk for developing a health care-associated infection?

Correct answer: C

Rationale: The correct answer is C. Using a clean technique for inserting a urinary catheter increases the risk for healthcare-associated infections. Invasive procedures like catheter insertion require a sterile technique to prevent introducing pathogens into the urinary tract. Choices A and B demonstrate appropriate infection control measures by emphasizing the use of sterile or aseptic techniques. Choice D represents an incorrect technique that can lead to the introduction of bacteria from the rectum into the urinary tract, potentially causing infections.

3. A nurse is assessing a client who is postoperative. Which of the following findings should the nurse prioritize?

Correct answer: C

Rationale: In a postoperative client, decreased urine output is a crucial finding as it can indicate impaired kidney function or inadequate fluid balance. Prioritizing assessment and intervention for decreased urine output is essential to prevent complications like acute kidney injury. Elevated temperature, low blood pressure, and increased heart rate are also important, but they may not be as urgent or directly related to kidney function in a postoperative client.

4. A nurse is assigned to care for a client with unstable blood pressure. What should the nurse do first?

Correct answer: B

Rationale: In the case of a client with unstable blood pressure, the priority action for the nurse is to continuously monitor the client's vital signs. This allows for immediate detection of any fluctuations in blood pressure and timely intervention if necessary. Choice A, monitoring every two hours, may not provide real-time information needed for prompt intervention. Choices C and D suggest waiting for instructions from the healthcare provider, which could cause a delay in addressing the unstable blood pressure, potentially leading to adverse outcomes. Therefore, the most appropriate initial action is to continuously monitor the client's vital signs.

5. A patient is admitted with signs of stroke. Which of the following diagnostic tests should the nurse anticipate as the priority?

Correct answer: A

Rationale: A CT scan is the priority diagnostic test to identify and confirm the location and severity of a stroke.

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