which action by the nurse is most important after discovering a patient on the floor who reports i fell out of bed which action by the nurse is most important after discovering a patient on the floor who reports i fell out of bed
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN

1. What is the most important action for the nurse to take after finding a patient on the floor who reports, 'I fell out of bed'?

Correct answer: C

Rationale: The most important action for the nurse to take after finding a patient on the floor who reports falling out of bed is to notify the health care provider. This is crucial to ensure that the incident is reported, documented, and that the patient receives necessary follow-up care. Reassessing the patient is important, but notifying the healthcare provider takes precedence to address any potential injuries or issues that may have resulted from the fall. Completing an incident report is necessary, but immediate notification to the healthcare provider is more critical in this situation. Doing nothing is not an appropriate response, as the patient's safety and well-being must be the top priority.

2. A client was exposed to anthrax. Which of the following antibiotics should the nurse plan to administer?

Correct answer: Ciprofloxacin

Rationale: In the case of anthrax exposure, the recommended antibiotic for prophylaxis and treatment is Ciprofloxacin. Ciprofloxacin is effective against the anthrax bacterium, Bacillus anthracis. Fluconazole is an antifungal medication, Tobramycin is an aminoglycoside antibiotic used for bacterial infections, and Vancomycin is a glycopeptide antibiotic primarily used for Gram-positive bacterial infections. Therefore, the correct choice is Ciprofloxacin.

3. Which foods are the biggest contributors of saturated fats consumed by Americans?

Correct answer: D

Rationale: The correct answer is D: Cheese, pizza, desserts, and chicken. These foods are significant contributors to the intake of saturated fats in the American diet, often found in processed and fast foods. Choices A, B, and C are incorrect because while butter, coconut, and palm oils (A) are sources of saturated fats, they are not the biggest contributors in the American diet. Corn oil (B) is a source of unsaturated fats, and meat and milk (C) contain saturated fats but are not the primary contributors compared to cheese, pizza, desserts, and chicken.

4. Which condition is characterized by the sudden onset of shortness of breath, often occurring at night and associated with heart failure?

Correct answer: A

Rationale: Paroxysmal nocturnal dyspnea is the correct answer. It is characterized by the sudden onset of shortness of breath during sleep, often associated with heart failure. Choice B, Sleep apnea, involves pauses in breathing during sleep but is not specifically associated with heart failure. Choice C, Orthopnea, is difficulty breathing that occurs when lying down and is relieved by sitting up, not necessarily associated with heart failure. Choice D, Dyspnea, is a general term for difficulty breathing and does not specifically describe the sudden onset at night associated with heart failure as seen in paroxysmal nocturnal dyspnea.

5. A client's plasma Lithium level is 2.1 mEq/L. Which of the following is an appropriate action by the nurse?

Correct answer: A

Rationale: In a client with a plasma lithium level of 2.1 mEq/L, immediate gastric lavage is appropriate for severe toxicity. Gastric lavage can help lower the client's lithium level by removing the unabsorbed lithium from the stomach.

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