what is the first action for a nurse when a patient experiences a fall
Logo

Nursing Elites

ATI RN

ATI RN Comprehensive Exit Exam

1. What is the first action for a healthcare provider when a patient experiences a fall?

Correct answer: A

Rationale: The correct answer is to 'Assess the patient for injuries' when a patient experiences a fall. This is crucial to promptly identify any injuries and provide appropriate care. Calling for help may be necessary, but assessing the patient's condition takes precedence to ensure immediate attention to any injuries. Documenting the fall and notifying the healthcare provider would follow after the initial assessment and necessary actions have been taken.

2. A nurse is reviewing the laboratory values of a client who has diabetic ketoacidosis (DKA). Which of the following findings should the nurse report to the provider?

Correct answer: B

Rationale: The correct answer is B. A glucose level of 250 mg/dL indicates hyperglycemia, which is expected in DKA. However, in the context of DKA management, persistent or worsening hyperglycemia can indicate inadequate treatment response or complications, necessitating further monitoring and intervention. Potassium levels are crucial in DKA due to the risk of hypokalemia, but a level of 4.2 mEq/L is within the normal range. Bicarbonate levels are typically low in DKA, making a value of 20 mEq/L consistent with the condition. Sodium levels of 135 mEq/L are also within normal limits and not a priority for immediate reporting in the context of DKA.

3. A nurse is caring for a client who has cirrhosis. Which of the following laboratory values should the nurse expect to be elevated?

Correct answer: B

Rationale: The correct answer is B: Ammonia. In clients with cirrhosis, impaired liver function can lead to elevated levels of ammonia in the blood. Elevated ammonia levels can result in hepatic encephalopathy, a condition characterized by altered mental status. Serum albumin (Choice A) is typically decreased in cirrhosis due to the liver's reduced synthetic function. Bilirubin (Choice C) levels can be elevated in liver disease but may not always be the most specific marker for cirrhosis. Prothrombin time (Choice D) is prolonged in cirrhosis due to impaired liver synthesis of clotting factors.

4. A client is receiving morphine for pain management. Which of the following findings should the nurse report to the provider?

Correct answer: C

Rationale: A respiratory rate of 10/min indicates respiratory depression, a serious adverse effect of morphine that should be reported immediately. While a heart rate of 88/min, pain rating of 4, and a temperature of 37.2°C (99°F) are within normal ranges and do not indicate immediate concern related to morphine administration.

5. What is the best intervention for a patient experiencing respiratory distress?

Correct answer: A

Rationale: Administering oxygen is the best intervention for a patient experiencing respiratory distress because it helps improve oxygenation and alleviate respiratory distress. Oxygen therapy is a critical and priority intervention in such cases as it aims to increase oxygen levels in the blood. Administering bronchodilators may be beneficial for specific respiratory conditions like asthma or COPD, but oxygen should be the initial priority. Administering IV fluids and providing humidified air, while important in certain situations, are not the primary interventions for respiratory distress.

Similar Questions

A client is being taught about a new prescription for furosemide. Which of the following statements by the client indicates an understanding of the teaching?
Which lab test is used to assess renal function?
A nurse is caring for a client who is at risk for pressure ulcers. Which of the following interventions should the nurse implement?
A client who is postoperative following a colon resection reports pain. Which of the following actions should the nurse take?
If a nurse administers an incorrect dose of medication, which fact related to the incident report should the nurse document in the client's medical record?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses