what is the nurses priority action when a patient has a fever
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment A

1. What is the priority action for a patient with a fever?

Correct answer: B

Rationale: The priority action when a patient has a fever is to assess the patient's temperature regularly. Monitoring the temperature helps track the effectiveness of interventions and detect any worsening fever. Administering antipyretic medication (Choice A) should be done based on healthcare provider's orders after assessing the patient's condition. While providing cooling measures such as a cool compress (Choice C) can help reduce fever, assessing the temperature takes precedence. Providing blankets for comfort (Choice D) is not the priority when dealing with a fever.

2. What are the clinical signs of hyperglycemia in a patient with diabetes mellitus, and how should a nurse respond?

Correct answer: B

Rationale: The correct signs of hyperglycemia in a patient with diabetes mellitus are polyuria (excessive urination), polydipsia (excessive thirst), and polyphagia (excessive hunger). These symptoms indicate high blood sugar levels. Therefore, the correct response for a nurse would be to recognize these signs, monitor blood glucose levels, and administer insulin to manage the hyperglycemia. Choice A is incorrect because it only addresses the response aspect without mentioning the signs. Choices C and D are incorrect as they do not reflect the classic clinical signs of hyperglycemia in diabetes mellitus.

3. A nurse is teaching the partner of a client who had a stroke about manifestations of dysphagia. Which of the following statements by the client's partner indicates the need for further teaching?

Correct answer: D

Rationale: The correct answer is D. Tilting the head forward during swallowing is not a compensatory technique for dysphagia and may increase the risk of aspiration. Choices A, B, and C are correct statements indicating appropriate monitoring for manifestations of dysphagia: coughing while eating, pocketing food in the mouth, and changes in voice after swallowing are all signs that should be monitored.

4. A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take in accordance with hospital policy?

Correct answer: B

Rationale: The correct answer is B because patients on fall precautions need continuous monitoring until discharge to prevent falls. While encouraging visitors during visiting hours (Choice A) is important for the patient's well-being, it is not related to fall precautions. Checking on the patient every shift (Choice C) is an essential nursing intervention, but keeping the patient on fall precautions is more specific to preventing falls. Raising all four side rails (Choice D) is not recommended as it can restrict the patient's mobility and is considered a restraint practice.

5. Which action by the nurse will help reduce the risk of venous thromboembolism (VTE) in a postoperative patient?

Correct answer: A

Rationale: The correct answer is to encourage early ambulation and leg exercises. By promoting early ambulation and leg exercises, blood flow is enhanced, reducing the risk of venous thromboembolism (VTE) in postoperative patients. Choice B, applying compression stockings, helps prevent VTE but is not as effective as early ambulation and exercises. Choice C, administering anticoagulants, is important in VTE prevention but does not directly address improving circulation through physical activity. Choice D, elevating the patient's legs, may be beneficial for circulation in specific cases but is not as effective in preventing VTE as early ambulation and leg exercises.

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