what is the appropriate action for a nurse to take when a patient has a high fever and is disoriented what is the appropriate action for a nurse to take when a patient has a high fever and is disoriented
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Nursing Elites

ATI RN

ATI RN Comprehensive Exit Exam

1. What is the appropriate action for a healthcare provider to take when a patient has a high fever and is disoriented?

Correct answer: C

Rationale: Administering fluids is the appropriate action for a healthcare provider to take when a patient has a high fever and is disoriented. Dehydration can worsen confusion and other symptoms in such a situation. Administering acetaminophen or cooling the patient with cold compresses may help reduce the fever but does not address the underlying issue. Administering antibiotics is not indicated for a high fever and disorientation without knowing the cause.

2. A client in labor is receiving IV Opioid analgesics. Which of the following actions should the nurse take?

Correct answer: B

Rationale: When a client is receiving IV Opioid analgesics during labor, the nurse should offer oral hygiene every 2 hours. Opioid analgesics can cause adverse effects like dry mouth, nausea, and vomiting. Providing oral hygiene care helps alleviate these symptoms and maintains the client's comfort and well-being during labor. Instructing the client to self-ambulate every 2 hours is not appropriate during labor as mobility may be limited. Anticipating medication administration 2 hours prior to delivery is not necessary as the timing of medication administration should be based on the client's needs and the progress of labor. Monitoring fetal heart rate every 2 hours is important during labor, but it is not specifically related to the client receiving IV Opioid analgesics.

3. A nurse is planning care for a client with thrombocytopenia. Which action should the nurse include?

Correct answer: C

Rationale: The correct action the nurse should include for a client with thrombocytopenia is to provide a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Providing a stool softener helps prevent constipation, straining, and subsequent bleeding, which is crucial for clients with thrombocytopenia. Encouraging the client to floss daily (Choice A) is important for oral hygiene but not directly related to thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is more related to infection control than managing thrombocytopenia. Avoiding serving raw vegetables (Choice D) is important for clients with compromised immune systems to reduce the risk of foodborne illnesses but is not directly related to thrombocytopenia management.

4. Lillian uses flowcharts to map the precise steps individuals use to solve problems and complete tasks. Lillian is a(n) __________ theorist.

Correct answer: B

Rationale: Lillian, who uses flowcharts to map precise steps individuals use to solve problems and complete tasks, is likely an information-processing theorist. Information-processing theorists focus on how people take in, store, and retrieve information to solve problems and make decisions, which aligns with Lillian's use of flowcharts to map out problem-solving steps.

5. Absorption is the ability to exhale carbon dioxide.

Correct answer: False

Rationale: Absorption is the process of taking in substances such as nutrients or gases. Exhaling carbon dioxide is a part of the process of respiration, not absorption. Therefore, the statement that absorption is the ability to exhale carbon dioxide is false. Choice A is incorrect because absorption does not involve exhaling carbon dioxide. Choice C is incorrect as the concept of absorption can be clearly defined. Choice D is also incorrect as there is a definitive answer to the statement provided.

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