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

Correct answer: B

Rationale: The correct first action for the nurse to take when receiving a report of a client's blood pressure reading of 160/95 is to recheck the blood pressure. Rechecking the blood pressure ensures the accuracy of the reading before making any further decisions or interventions. Notifying the provider (Choice A) can be considered after confirming the blood pressure reading. Administering antihypertensive medication (Choice C) should not be done based solely on one reading without verification. Documenting the blood pressure in the chart (Choice D) should also come after confirming the accuracy of the reading to avoid recording incorrect information.

2. A nurse is caring for a client who is experiencing fluid volume deficit (FVD). What clinical finding should the nurse expect?

Correct answer: B

Rationale: Increased heart rate is a common sign of fluid volume deficit (FVD) as the body compensates for decreased fluid levels. When a client is experiencing FVD, the body tries to maintain perfusion to vital organs by increasing the heart rate. This compensatory mechanism helps to improve cardiac output and maintain blood pressure. Choices A, C, and D are incorrect because in FVD, hematocrit may be increased due to hemoconcentration, blood pressure tends to decrease as a compensatory response to FVD, and respiratory rate is usually unaffected or may increase due to attempts to maintain oxygenation.

3. A healthcare professional is teaching a group of assistive personnel about the expected integumentary changes in older adults. Which change should the healthcare professional include?

Correct answer: C

Rationale: The correct answer is C: Decrease in moisture levels. In older adults, there is a reduction in oil production, leading to decreased moisture levels in the skin. This change can result in dry skin and increased risk of skin issues. The other choices are incorrect because in older adults, skin turgor tends to decrease, subcutaneous fat may decrease, and oil production typically decreases rather than increases.

4. A nurse is caring for a client who has an indwelling urinary catheter. What finding indicates a catheter occlusion?

Correct answer: A

Rationale: Bladder distention is the correct finding that indicates a catheter occlusion. When the catheter is occluded, urine cannot drain properly, leading to the build-up of urine in the bladder, causing distention. Bladder spasms (Choice B) are not typically associated with catheter occlusion but may indicate irritation or infection. Hematuria (Choice C) refers to blood in the urine and is not specific to catheter occlusion. Increased urine output (Choice D) is not indicative of catheter occlusion but may suggest other conditions like diabetes insipidus.

5. A client signed an informed consent form for surgery but has expressed doubts about the need for surgery. What should the nurse say?

Correct answer: B

Rationale: The correct answer is B because the surgeon should address the client's doubts before surgery. Informed consent requires that the client fully understands the procedure. Choice A is incorrect because reassuring the client of the surgeon's skill does not address the client's doubts about the need for surgery. Choice C is incorrect because telling the client surgery is necessary may not address their concerns and could violate the principle of autonomy. Choice D is incorrect as the immediate concern is addressing the client's doubts before surgery, not necessarily seeking a second opinion.

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