what is the primary action when a nurse discovers a patient has fallen

ATI RN

ATI RN Exit Exam Test Bank

1. What is the primary action when a healthcare provider discovers a patient has fallen?

A. Assess the patient for injuries
B. Call for help immediately
C. Document the fall
D. Notify the healthcare provider

Correct answer: A

Rationale: When a healthcare provider discovers a patient has fallen, the primary action should be to assess the patient for injuries. This is crucial to determine the extent of harm and if immediate treatment is necessary. Calling for help is important, but assessing the patient's condition takes precedence to ensure the patient's safety and well-being. While documenting the fall and notifying the healthcare provider are essential steps, they come after assessing the patient's injuries.

2. Which electrolyte imbalance is common in patients receiving diuretics?

A. Hypokalemia
B. Hypercalcemia
C. Hyponatremia
D. Hypermagnesemia

Correct answer: A

Rationale: The correct answer is Hypokalemia. Diuretics, such as furosemide, commonly cause potassium loss in patients, leading to hypokalemia. This electrolyte imbalance should be closely monitored to prevent complications like cardiac arrhythmias. Hypercalcemia (Choice B) is not typically associated with diuretic use. Hyponatremia (Choice C) involves low sodium levels and can occur in conditions like syndrome of inappropriate antidiuretic hormone secretion (SIADH) but is not directly caused by diuretics. Hypermagnesemia (Choice D) is an excess of magnesium, usually not a common electrolyte imbalance induced by diuretics.

3. How should signs of infection in a post-surgical patient be assessed?

A. Check the surgical site
B. Check the patient's vital signs
C. Monitor for fever
D. Check for abnormal breath sounds

Correct answer: A

Rationale: Assessing the surgical site is crucial in identifying early signs of infection post-surgery. Changes such as redness, swelling, warmth, or drainage may indicate an infection developing. While monitoring vital signs and fever are important in infection assessment, they are general indicators and may not show localized signs at the surgical site. Checking for abnormal breath sounds is more relevant when assessing respiratory issues rather than infection at the surgical site.

4. A nurse is planning care for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care?

A. Place the client in seclusion when she is confused.
B. Request a prescription for PRN restraints when the client is wandering.
C. Dim the lighting in the client's room.
D. Leave one side rail up on the client's bed.

Correct answer: C

Rationale: The correct answer is to dim the lighting in the client's room. Dim lighting can help reduce confusion and agitation in clients with Alzheimer's disease. Placing the client in seclusion (Choice A) is not recommended as it can lead to feelings of isolation and distress. Requesting PRN restraints (Choice B) should be avoided in clients with Alzheimer's as it can increase agitation and pose safety risks. Leaving one side rail up on the client's bed (Choice D) may not directly address the client's confusion and wandering behavior.

5. A nurse is reviewing the laboratory results of a client who is at 28 weeks of gestation. Which of the following laboratory values should the nurse report to the provider?

A. Hgb 10 g/dL
B. Platelets 300,000/mmÂ³
C. WBC count 12,000/mmÂ³
D. BUN 18 mg/dL

Correct answer: A

Rationale: The correct answer is A: Hgb 10 g/dL. A hemoglobin level of 10 g/dL is below the normal range for a pregnant client, indicating possible anemia, which is crucial to report during pregnancy to prevent complications for both the mother and the baby. Platelets, WBC count, and BUN levels within the listed values are generally within normal ranges for a pregnant individual at 28 weeks of gestation. Platelets play a role in blood clotting, WBC count helps in fighting infections, and BUN measures kidney function, all of which are typically expected to be within normal limits during pregnancy.