a patient requires assistance to stand from a sitting position which action by the nurse ensures patient safety
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Nursing Elites

ATI RN

ATI Capstone Comprehensive Assessment B

1. A patient requires assistance to stand from a sitting position. Which action by the nurse ensures patient safety?

Correct answer: B

Rationale: The correct answer is B. Placing a gait belt around the patient for support is the safest option when assisting a patient to stand from a sitting position. This belt provides stability and support, reducing the risk of falls or injuries during the transfer. Choices A, C, and D are incorrect. Allowing the patient to pull up on the nurse's arm (Choice A) may lead to instability and compromise safety. Having the patient push off the chair with their hands (Choice C) might not provide sufficient support, especially for patients who require assistance. Asking the patient to lift themselves up without support (Choice D) can be dangerous and increase the risk of falls.

2. A patient is being treated for dehydration. Which lab result would support the diagnosis?

Correct answer: D

Rationale: Elevated BUN levels are a characteristic finding in dehydration due to reduced kidney perfusion and increased reabsorption of urea. Hemoglobin levels might be elevated in conditions like polycythemia vera, not directly related to dehydration. A low sodium level could be seen in conditions like hyponatremia. A high white blood cell count is more indicative of infection or inflammation rather than dehydration.

3. A hospice nurse is providing teaching to a client who has a new diagnosis of a terminal illness and her family. Which of the following statements should the nurse include in the teaching?

Correct answer: D

Rationale: The correct answer is D because hospice care provides ongoing support to families with grief even after a patient's death. Choice A is incorrect because hospice care focuses on providing comfort and symptom management rather than disease treatment and rehabilitation. Choice B is incorrect as the statement does not accurately reflect the role of a hospice provider. Choice C is incorrect; a family caregiver is not a prerequisite for admission into a hospice facility.

4. How should a healthcare provider manage a patient with deep vein thrombosis (DVT)?

Correct answer: A

Rationale: Corrected Rationale: Monitoring for signs of pulmonary embolism is crucial in patients with deep vein thrombosis (DVT) as it can be a life-threatening complication. While administering anticoagulants as prescribed is important for preventing clot progression, the immediate concern is detecting potential pulmonary embolism. Applying compression stockings and encouraging leg elevation are beneficial measures for managing DVT symptoms but are not as critical as monitoring for pulmonary embolism.

5. A client with left hemiparesis is learning how to use a cane. Which of the following instructions should the nurse include?

Correct answer: D

Rationale: The correct way to use a cane for a client with left hemiparesis is to hold the cane on the right side to provide support for the weaker left leg. This allows for better stability and weight distribution. Placing the cane approximately 61 cm (24 in) in front of their feet before advancing (Choice A) is not necessary and may lead to improper gait. Advancing the stronger leg and the cane together (Choice B) is incorrect as it does not provide support for the weaker leg. Removing the rubber tip when using the cane (Choice C) is also incorrect as the rubber tip helps provide traction and stability.

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