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

ATI RN

ATI RN Exit Exam Test Bank

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

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. What is the appropriate nursing response when a patient refuses blood transfusion due to religious beliefs?

Correct answer: A

Rationale: The correct answer is A: "Respect the patient's decision and notify the provider." When a patient refuses a blood transfusion due to religious beliefs, it is essential to respect their autonomy and religious beliefs. Attempting to persuade the patient (Choice B) goes against the principle of respect for autonomy and can lead to ethical dilemmas. Documenting the refusal and notifying the healthcare provider (Choice C) is important for legal and ethical purposes but should be preceded by respecting the patient's decision. Providing education on the benefits of blood transfusion (Choice D) may be appropriate in other situations but is not indicated when a patient refuses based on religious beliefs.

3. 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.

4. A nurse is preparing discharge information for a client who has type 2 diabetes mellitus. Which of the following resources should the nurse provide to the client?

Correct answer: D

Rationale: The correct answer is D. Food exchange lists from the American Diabetes Association are valuable resources for individuals with diabetes as they provide specific guidance on meal planning and portion control, which are crucial for managing blood sugar levels. Choice A is incorrect because personal blogs may not always provide accurate or evidence-based information. Choice B is incorrect as food label recommendations, while important, may not offer the structured guidance needed for meal planning in diabetes. Choice C is also incorrect as medication information is different from dietary guidance needed for diabetes management.

5. A client has a new prescription for furosemide. Which of the following instructions should the nurse include during discharge teaching?

Correct answer: C

Rationale: The correct instruction for a client taking furosemide is to increase their intake of potassium-rich foods. Furosemide is a loop diuretic that can lead to potassium loss, so increasing potassium-rich foods helps prevent hypokalemia. Choice A, avoiding prolonged exposure to sunlight, is not directly related to furosemide use. Choice B, taking the medication with a meal, is not a specific requirement for furosemide administration. Choice D, limiting fluid intake to 1 liter per day, is not the correct advice as furosemide is a diuretic that often requires increased fluid intake to prevent dehydration.

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