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 patient with a left arm fracture reports severe pain unrelieved by medication. What should the nurse assess for?

Correct answer: A

Rationale: Correct answer: When a patient with a left arm fracture reports severe pain unrelieved by medication, the nurse should assess for compartment syndrome. Compartment syndrome is a condition where increased pressure within a muscle compartment compromises circulation and can lead to tissue damage. It is a surgical emergency that requires immediate intervention. Choice B is incorrect because simply increasing pain medication without identifying the cause of the unrelieved pain may mask symptoms of a serious issue like compartment syndrome. Choice C is incorrect as surgery would only be necessary if compartment syndrome is confirmed. Choice D is incorrect as administering a sedative does not address the underlying issue of unrelieved pain and may delay appropriate treatment.

3. Which action should the nurse take to minimize the risk of medication errors?

Correct answer: B

Rationale: The correct answer is B because ensuring two nurses double-check medications before administration is a crucial step in minimizing the risk of medication errors. This practice helps in verifying the accuracy of medication orders and reducing the chances of mistakes. Choice A may not necessarily prevent errors as preparing medications ahead of time does not guarantee accuracy. Choice C, administering medications at the same time each day, is important for consistency but does not directly address the risk of errors. Choice D, relying on memory, is highly discouraged as it increases the likelihood of errors due to human forgetfulness.

4. A nurse is caring for a patient with an infection. Which laboratory result is most important to monitor?

Correct answer: A

Rationale: The correct answer is A: White blood cell count (WBC). Monitoring the white blood cell count is crucial when caring for a patient with an infection as it helps assess the body's response to the infection. An elevated white blood cell count often indicates an active infection or inflammation, while a decreasing count may signal improvement or potential complications. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are nonspecific markers of inflammation and not as specific to monitoring infection progression as the white blood cell count. Hemoglobin and hematocrit levels are important for assessing oxygen-carrying capacity and blood volume, but they are not the primary indicators for monitoring infection.

5. A nurse manager on an acute care unit is preparing a staff presentation about promoting cost-effective care. Which of the following strategies should the nurse plan to include in the presentation?

Correct answer: D

Rationale: Teaching staff proper use of PPE helps reduce the spread of infections and promotes cost-effective care.

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