when caring for a client diagnosed with delirium which condition is most important for the nurse to investigate
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Nursing Elites

ATI LPN

ATI NCLEX PN Predictor Test

1. When caring for a client diagnosed with delirium, which condition is most important for the nurse to investigate?

Correct answer: C

Rationale: When caring for a client diagnosed with delirium, the most important condition for the nurse to investigate is prescription drug intoxication. Delirium can be caused by various factors, and prescription drug intoxication is a common reversible cause. Investigating this factor first is crucial to identify and address the underlying cause promptly. Choices A, B, and D are less likely to be directly associated with delirium compared to prescription drug intoxication. While cancer, impaired hearing, and heart failure can have their complications and effects, they are not typically the primary causes of delirium in a client.

2. A client is using a metered-dose inhaler (MDI) for asthma management. Which of the following actions by the client indicates an understanding of the teaching?

Correct answer: C

Rationale: The correct answer is to hold your breath for 5-10 seconds after inhaling when using a metered-dose inhaler (MDI) for asthma management. This action ensures proper medication absorption in the lungs. Inhaling rapidly (choice A) may cause the medication to impact the mouth/throat rather than the lungs. Exhaling completely before inhalation (choice B) does not optimize medication delivery. Inhaling slowly (choice D) may not allow the medication to reach the lungs effectively.

3. While performing assessments on newborns in the nursery, which finding should the nurse report to the provider?

Correct answer: A

Rationale: A respiratory rate of 70 in a two-day old newborn is above the normal range and should be reported to the provider. This finding may indicate respiratory distress or another underlying issue that needs prompt attention. Choices B, C, and D are within normal limits for newborns and do not require immediate reporting to the provider.

4. A nurse is providing teaching to a client who is to start taking digoxin. Which of the following statements by the client indicates an understanding of the teaching?

Correct answer: B

Rationale: The client should contact their provider if their heart rate drops below 60 beats per minute, as this could indicate digoxin toxicity.

5. A client who has undergone vein ligation and stripping to treat varicose veins should be instructed to do which of the following activities during discharge teaching?

Correct answer: B

Rationale: The correct answer is B: 'Walk for 1-2 hours each day.' After vein ligation and stripping, walking helps promote circulation and aids in the recovery process. Option A is incorrect as remaining sedentary for 2-3 days can lead to decreased circulation and potentially increase the risk of complications. Option C is incorrect because compression stockings should typically be worn during the day to support circulation. Option D is incorrect as elevating the legs while sitting is beneficial, but walking is more effective in promoting circulation and recovery in this case.

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