which action is most appropriate for a nurse to take when a patient is at risk for falls
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Nursing Elites

ATI RN

ATI Capstone Comprehensive Assessment B

1. What is the most appropriate action for a healthcare provider to take when a patient is at risk for falls?

Correct answer: B

Rationale: The correct answer is to apply a yellow fall risk bracelet to the patient. This action helps alert staff to the patient's increased risk of falling, prompting them to implement appropriate safety measures and precautions. Placing the call light within reach (choice A) is generally important but does not specifically address fall risk. Assisting the patient when ambulating (choice C) is important but may not be sufficient alone to prevent falls. Ensuring the patient's room is well-lit (choice D) is also crucial for patient safety but does not directly address the patient's fall risk status.

2. How can a healthcare professional help prevent pressure ulcers in an immobile patient?

Correct answer: A

Rationale: Ensuring proper nutrition and hydration is crucial in preventing pressure ulcers in immobile patients. Adequate nutrition supports tissue health and repair, while hydration helps maintain skin elasticity. While turning the patient every 2 hours is important to prevent pressure injuries, it is not the primary way to address prevention. Using moisture barriers and providing special mattresses or padding are essential components of pressure ulcer prevention, but they are not as fundamental as ensuring proper nutrition and hydration.

3. A patient is on contact precautions for an infection. What is the most important action for the nurse to take?

Correct answer: A

Rationale: The most important action for the nurse to take when caring for a patient on contact precautions is to wear gloves when entering the patient's room. This is crucial in preventing the spread of infection from the patient to the healthcare provider and vice versa. Placing the patient in a private room may be necessary for airborne precautions but is not specifically related to contact precautions. Using a dedicated blood pressure cuff for the patient is important for preventing cross-contamination but is not the most critical action. Disposing of equipment in a biohazard bag is a standard procedure but is not the most important action in this scenario.

4. The nurse has received a report from the emergency department that a patient with tuberculosis will be coming to the unit. Which items will the nurse need to care for this patient?

Correct answer: A

Rationale: The correct answer is A. Caring for a patient with tuberculosis requires the nurse to use an N95 respirator, gown, gloves, and eyewear to protect against airborne transmission of the disease. Choice B and D are incorrect because while communication signs for precautions are important, the essential items needed for caring for a patient with tuberculosis are personal protective equipment to prevent transmission. Choice C is also incorrect as negative-pressure airflow in the room is a facility-related requirement and not an item carried by the nurse.

5. The nurse asks a client who is about to have a cardiac catheterization about any allergies. The client states, 'I always get a rash when I eat shellfish.' Which of the following is the priority nursing action?

Correct answer: D

Rationale: Notifying the provider of the client's shellfish allergy is crucial to prevent a potential reaction from the contrast dye. While attaching a wristband indicating the allergy may be necessary, the priority is to inform the provider. Asking the client about other foods causing a similar reaction or notifying the dietary department, although important, are not the priority in this situation.

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