a nurse is teaching an older adult client who has left sided weakness about cane use which of the following instructions should the nurse include
Logo

Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment Form A

1. A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?

Correct answer: C

Rationale: The correct instruction for a client with left-sided weakness using a cane is to move the left foot forward first. This technique helps improve stability and safety by ensuring weight-bearing on the stronger side while providing support with the cane. Choice A is incorrect because the cane should be held on the stronger side, which is the right side in this case. Choice B is incorrect as the recommended distance to move the cane forward with each step is about 6 inches, not 18 inches. Choice D is incorrect as it is essential to maintain a slight bend in the elbow while using the cane to absorb shock and provide flexibility.

2. A nurse is preparing to administer a high dose of morphine to a patient with terminal cancer. What is the nurse's primary consideration before administration?

Correct answer: B

Rationale: The correct answer is B: Monitor the patient for respiratory depression. When administering a high dose of morphine, the nurse's primary consideration should be to monitor the patient for respiratory depression, as morphine can slow down breathing, especially in higher doses. Option A is incorrect because the primary focus should be on the patient's well-being and safety rather than family awareness at this point. Option C is not the best approach as the immediate concern is monitoring the patient closely for any adverse effects. Option D is not advisable as delaying administration without a valid reason can compromise pain management in a terminal cancer patient.

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 healthcare professional is assessing a patient's fluid balance. What is the most reliable indicator of fluid status?

Correct answer: B

Rationale: Checking the patient's weight daily is the most reliable indicator of fluid status because weight changes can directly reflect fluid retention or loss. Monitoring vital signs (Choice A) can provide some information but is not as specific as weight changes. Measuring intake and output (Choice C) is crucial but may not always accurately reflect fluid balance. Monitoring urine color (Choice D) can give some insights into hydration levels, but it is not as reliable as daily weight checks for assessing overall fluid status.

5. A staff nurse is challenging a shift assignment with the charge nurse. Which of the following statements made by the charge nurse is an example of smoothing as a strategy to resolve conflict?

Correct answer: D

Rationale: The correct answer is D because it exemplifies smoothing as a conflict resolution strategy. Smoothing involves downplaying conflict and reassuring the individual to reduce tension. In this statement, the charge nurse acknowledges the staff nurse's experience and capability to perform the assigned tasks, which aims to reduce conflict and promote a positive outlook. Choices A, B, and C do not reflect smoothing. Choice A involves a conditional agreement, choice B introduces a threat of reporting, and choice C shifts the focus away from the conflict.

Similar Questions

A nurse is assessing a client who has heart failure and is taking digoxin. The nurse should monitor the client for which of the following manifestations as an indication of digoxin toxicity to report to the provider?
Which of the following is a recommended approach for handling aggressive behavior in a mental health setting?
A nurse is assessing the skin of an immobilized patient. What will the nurse do?
How can a healthcare professional help prevent pressure ulcers in an immobile patient?
A nurse manager is presenting to a group of unit nurses the categories regulated under the Controlled Substances Act. Which of the following medications should the nurse include under Schedule II?

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