a nurse receives a report from an assistive personnel that a clients bp is 16095 what should the nurse do first
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Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. A nurse receives a report from an assistive personnel that a client's BP is 160/95. What should the nurse do first?

Correct answer: C

Rationale: The correct first action for the nurse in this scenario is to recheck the blood pressure. This step is crucial to confirm the accuracy of the initial reading. Administering antihypertensive medication without verifying the blood pressure could lead to inappropriate treatment. Notifying the healthcare provider can be done after ensuring the accuracy of the reading. Simply documenting the blood pressure without validation may result in acting on potentially incorrect information. Therefore, the priority is to recheck the blood pressure.

2. A nurse is monitoring a client who is receiving continuous enteral feedings. What finding suggests the client is not tolerating the feeding?

Correct answer: B

Rationale: Nausea is a common sign indicating that the client is not tolerating enteral feedings well. It can be a result of various issues such as feeding intolerance, infection, or other underlying conditions. Nausea should be promptly addressed to prevent further complications. Increased bowel sounds (Choice A) are not typically indicative of feeding intolerance. Elevated blood pressure (Choice C) and fever (Choice D) are generally not directly related to enteral feeding intolerance unless there are specific underlying conditions contributing to them.

3. A client with an indwelling urinary catheter is being cared for by a nurse. What finding indicates a catheter occlusion?

Correct answer: A

Rationale: Bladder distention is the correct answer as it indicates that the catheter is not draining properly, which is a sign of occlusion. Frequent urination, hematuria, and burning sensation are not indicative of a catheter occlusion. Frequent urination may suggest a bladder that is not fully emptying, hematuria indicates blood in the urine, and a burning sensation can be a sign of a urinary tract infection, none of which directly relate to a catheter occlusion.

4. A nurse is reviewing the health history of a client who has a hip fracture. What risk factor should the nurse identify for developing pressure injuries?

Correct answer: B

Rationale: Corrected Rationale: Poor nutrition increases the risk of developing pressure injuries as it impairs skin integrity and healing. Frequent repositioning, increased fluid intake, and the use of a special mattress are all important interventions for preventing pressure injuries, rather than risk factors for developing them. Repositioning helps relieve pressure, adequate fluid intake maintains skin hydration, and special mattresses redistribute pressure to prevent injuries.

5. A nurse is caring for a client who reports a decrease in the effectiveness of their pain medication. What factor should the nurse identify as contributing to this decrease?

Correct answer: C

Rationale: The correct answer is C: Bowel inflammation. Bowel inflammation can interfere with the absorption of medications, including pain medication, leading to decreased effectiveness. Choices A, B, and D are incorrect because although they can impact pain management in various ways, they are not directly related to the decreased effectiveness of pain medication due to absorption issues.

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