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 just had a flexible bronchoscopy. Which of the following nursing actions is appropriate?

Correct answer: B

Rationale: After a flexible bronchoscopy, it is essential to withhold food and liquids until the client's gag reflex returns. This precaution helps prevent aspiration, as the gag reflex protects the airway from foreign material. Irrigating the client's throat every 4 hours (Choice A) is unnecessary and may increase the risk of aspiration. Suctioning the client's oropharynx frequently (Choice C) can cause trauma and is not indicated unless there is a specific medical reason for it. Having the client refrain from talking for 24 hours (Choice D) is not necessary after a flexible bronchoscopy.

3. The nurse is caring for a patient with an incision. Which actions will best indicate an understanding of medical and surgical asepsis for a sterile dressing change?

Correct answer: C

Rationale: Choice C is the correct answer. When performing a sterile dressing change, it is essential to use clean gloves to remove soiled dressings and sterile gloves and supplies for applying the new dressing. This helps maintain aseptic technique and reduce the risk of introducing pathogens to the wound. Choices A, B, and D involve incorrect use of sterile and clean supplies, which can compromise the sterility of the procedure and increase the risk of infection.

4. Which action by the nurse represents the ethical principle of beneficence?

Correct answer: B

Rationale: The correct answer is B. Beneficence is the ethical principle of doing good or acting in the best interest of the client. Preventing harm by providing accurate information and necessary care aligns with the principle of beneficence, as it focuses on promoting the well-being and safety of the client. Choices A, C, and D do not directly reflect the concept of beneficence. Ensuring all clients are treated fairly relates more to justice, allowing the client to refuse treatment pertains to autonomy, and ensuring the client's family agrees with the treatment involves collaboration and communication but not specifically beneficence.

5. A client has a new prescription for beclomethasone inhaler to use with an albuterol inhaler for asthma maintenance. What should the nurse instruct the client?

Correct answer: C

Rationale: The correct answer is to instruct the client to gargle with water after each use of the beclomethasone inhaler. Beclomethasone can cause oral thrush, and gargling with water helps prevent this complication. Choice A is incorrect because the client should not skip doses even if breathing improves, as the medications are prescribed for maintenance. Choice B is incorrect as there is no specific instruction to use the albuterol inhaler first in this scenario. Choice D is incorrect because inhalers should not be stored in the refrigerator unless specified by the manufacturer.

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