the nurses initial priority when managing a physically assaultive client is to
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Nursing Elites

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ATI PN Comprehensive Predictor

1. When managing a physically assaultive client, the nurse's INITIAL priority is to

Correct answer: C

Rationale: When dealing with a physically assaultive client, the initial priority is to focus on restoring the client's self-control and preventing further escalation. Restricting the client to the room (choice A) may escalate the situation and is not the initial priority. Placing the client under one-to-one supervision (choice B) is important but comes after ensuring the client's self-control. Clearing the immediate area of other clients (choice D) is essential for safety but is not the initial priority when compared to restoring the client's self-control.

2. How should a healthcare provider respond to a patient with a suspected pulmonary embolism?

Correct answer: A

Rationale: Administering oxygen and calling for emergency assistance are the immediate priorities when managing a suspected pulmonary embolism. Oxygen helps support the patient's respiratory function, while emergency assistance is crucial for further evaluation and treatment. Positioning the patient in a prone position or giving fluids can worsen the condition by impeding blood flow. Administering anticoagulants may be part of the treatment plan but is not the initial response. Thrombolytics and chest physiotherapy are not first-line treatments for suspected pulmonary embolism and can even be harmful without prior evaluation.

3. During the admission of a client with a latex allergy, which of the following supplies has the potential to contain latex?

Correct answer: A

Rationale: The correct answer is A: Urinary catheters. Urinary catheters often contain latex, which can trigger an allergic reaction in clients with latex allergy. Indwelling catheters (choice B), sterile gloves (choice C), and sterile gowns (choice D) can be latex-free alternatives. However, urinary catheters are more commonly made with latex, making them a higher risk for clients with latex allergies.

4. A nurse is reviewing the medical history of a client with dementia. Which of the following findings should the nurse address first?

Correct answer: A

Rationale: In a client with dementia, addressing restlessness and agitation is a priority because these symptoms can exacerbate dementia and lead to further complications. Restlessness and agitation can indicate underlying issues such as pain, discomfort, or unmet needs, which should be promptly assessed and managed to improve the client's quality of life. Decreased respiratory rate, wandering during the night, and incontinence are important to address but do not pose immediate risks to the client's well-being compared to the potential effects of unmanaged restlessness and agitation in dementia.

5. Which of the following is an expected side effect of furosemide?

Correct answer: B

Rationale: The correct answer is B, Hypokalemia. Furosemide is a loop diuretic that works by increasing the excretion of water and electrolytes, including potassium, leading to hypokalemia. Choice A, Bradycardia, is incorrect because furosemide does not typically cause a decrease in heart rate. Choice C, Increased blood pressure, is incorrect as furosemide is actually used to lower blood pressure by reducing fluid volume. Choice D, Increased urine output, is a common effect of furosemide due to its diuretic action but is not an adverse side effect.

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