a patient reports feeling dizzy when standing up what is the most appropriate nursing intervention
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Nursing Elites

ATI RN

ATI Capstone Comprehensive Assessment B

1. A patient reports feeling dizzy when standing up. What is the most appropriate nursing intervention?

Correct answer: B

Rationale: The correct answer is to assist the patient to sit down slowly. This intervention is appropriate for a patient experiencing dizziness when standing up, as it helps prevent falls due to orthostatic hypotension. Encouraging deep breaths (Choice A) may not address the underlying cause of dizziness, which is related to postural changes. Instructing the patient to use a walker for support (Choice C) or teaching the patient how to change positions safely (Choice D) are not the most immediate and direct interventions to address the immediate risk of falling when feeling dizzy upon standing.

2. A nurse enters a client's room to administer a prescribed medication, and the client asks about the medication. What is the most appropriate response by the nurse?

Correct answer: B

Rationale: The most appropriate response for the nurse when a client asks about a medication is to refer the client to the healthcare provider for more information. This ensures that the client receives accurate and detailed information from the appropriate source. Providing detailed information or a brief explanation as choices A and C suggest may not be within the nurse's scope of practice and could potentially lead to misinformation or confusion. Asking another nurse to explain the medication, as in choice D, may not guarantee accurate information, so it is best to involve the healthcare provider directly.

3. A nurse manager is teaching a group of employees about standards for Quality and Safety Education for Nurses (QSEN). Which of the following statements by an employee should the nurse manager identify as an example of the QSEN concept of quality improvement?

Correct answer: B

Rationale: Involving partners in care planning is a quality improvement strategy that aligns with QSEN principles. This choice reflects patient-centered care and collaboration, which are essential elements of quality improvement. Choices A, C, and D do not directly relate to quality improvement concepts. Tracking discharge times, logging out of computers, and providing change-of-shift reports are important practices but not specifically focused on quality improvement.

4. A nurse manager notes that a nurse is not following safety protocols. What should the manager do first?

Correct answer: B

Rationale: The correct first step for the nurse manager is to notify the hospital's safety committee. This action is crucial to ensure that the appropriate measures are taken promptly to address the non-compliance with safety protocols. Confronting the nurse directly may not be the best initial approach as involving the safety committee can provide a systematic and comprehensive response to the issue. Documenting the observation without addressing it or following up at a later time may delay the necessary actions to maintain a safe environment, making these choices less effective as the first course of action.

5. A nurse is providing teaching to a client who has schizophrenia about thioridazine. Which of the following instructions should the nurse include?

Correct answer: A

Rationale: The correct answer is A: 'Report any sign of infection to the provider immediately.' This instruction is essential for clients taking thioridazine or other antipsychotic medications. Thioridazine does not typically affect blood pressure or cause easy bruising. Muscle rigidity is more commonly associated with other antipsychotic medications. Reporting signs of infection promptly is crucial as antipsychotic medications can affect the immune system, making individuals more susceptible to infections. Early detection and treatment of infections help prevent complications and ensure proper medication management.

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