what is the most important nursing action when a patient experiences a fall
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Nursing Elites

ATI RN

ATI RN Exit Exam

1. What is the most important nursing action when a patient experiences a fall?

Correct answer: A

Rationale: The most important nursing action when a patient experiences a fall is to assess the patient for injuries. This is critical to identify any potential harm or underlying issues that may require immediate attention. Calling for help and notifying the healthcare provider are important steps, but assessing the patient's condition takes precedence to ensure prompt and appropriate care. Documenting the fall is also necessary but should follow the initial assessment and care provided to the patient.

2. A client with chronic kidney disease is being taught by a nurse about managing protein intake. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct answer is B: 'You should limit your intake of high-protein foods.' Clients with chronic kidney disease should restrict their intake of high-protein foods to lessen the workload on the kidneys and prevent further kidney damage. Option A is incorrect as increasing intake of high-protein foods can exacerbate the condition. Option C is incorrect as avoiding all protein sources is not advisable, as some proteins are essential for overall health. Option D is incorrect as increasing the intake of animal protein can put more strain on the kidneys due to the metabolites produced during protein breakdown.

3. How should a healthcare provider manage a patient with chronic pain?

Correct answer: A

Rationale: Administering prescribed analgesics is a crucial aspect of managing chronic pain effectively. Analgesics help alleviate pain symptoms and improve the patient's quality of life. While physical activity and non-pharmacological interventions can also play a role in pain management, the immediate need for relief in chronic pain often requires pharmacological intervention. Encouraging deep breathing exercises may provide some relief in certain situations, but it may not be as effective as analgesics for managing chronic pain.

4. What is the best position for a patient with respiratory distress?

Correct answer: A

Rationale: The best position for a patient with respiratory distress is the Semi-Fowler's position. This position promotes lung expansion and improves oxygenation by allowing the chest to expand more fully. The Trendelenburg position, where the patient's feet are higher than the head, is contraindicated in respiratory distress as it can increase pressure on the diaphragm and compromise breathing. The prone position, lying face down, may be beneficial in certain cases like acute respiratory distress syndrome but is not generally recommended for all patients in respiratory distress. The supine position, lying flat on the back, can worsen respiratory distress by causing the tongue to fall back and obstruct the airway.

5. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take to prevent infection?

Correct answer: B

Rationale: The correct answer is to change the TPN tubing every 24 hours. This action helps reduce the risk of infection because the high glucose content of TPN promotes bacterial growth. Choice A is incorrect as changing the tubing every 48 hours would not provide adequate infection prevention. Option C, monitoring urine output, is important for assessing renal function but is not directly related to preventing TPN-related infections. Option D, monitoring weight, is essential for assessing nutritional status but does not directly address infection prevention in TPN administration.

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