NCLEX RN ATI REVIEW. fully solved 2024

NCLEX RN ATI REVIEW.Contributing factors Fall - correct answer Older age Impaired mobility Cognitive and/or Sensory impairment Bowel and bladder dysfuntion Side effects of medications History of falls Nursing interventions Falls - correct answer Complete a fall risk assessment Communicate identified risks with the health care team Assign clients at risk falls to a room close to nurses' stations and assess frequently Provide clients with nonskid footwear Keep the floor free of clutter and maintain an unobstructed path to the bathroom Orient the client setting (grab bars, call light), including how to use and locate all necessary items Maintain bed in low position Instruct the client who is unsteady to use the call light for assistance before ambulating Answer call lights promptly to prevent clients who are at risk from trying to ambulate independently Provide adequate lighting (nightlight for necessary trips to the bathroom) Determine the client's ability to use assistive devices (walkers, canes, etc.). Keep all items within reach Use chair or bed sensors for client who are at risk Lock wheels on beds, wheelchairs, and gurneys to prevent rolling during transfers or stops Report and document all incidents per the facility policy Nursing intervention Restraints - correct answer Implement nonpharmacologic measures such as distraction, frequent observation, or diversion activities Prior to application, review manufacturer's instructions for correct application Notify the provider immediately when restraints are implemented Remove the restraints and assess client every 2 hr Assess neurovascular and neurosensory status every 2 hr Leave the restraint loose enough to prevent injury Always tie the restraint to the bed frame (using loose knots that are easily removed) Reassess the need for continue use Document Document Restraints - correct answer Behaviors making restraint necessary Alternatives attempted and the client's response Type and location of restraint and time applied Frequency and type of assessment Restraints should NEVER - correct answer Interfere with treatment Be used because of short-staffing or staff convenience Not written as PRN orders Nursing intervention Seizure precaution - correct answer Assess seizure history, noting frequency, presence of auras, and sequence of events Identify precipitating factors that may exacerbate or lead to seizure Review medication history. If routine lab work is required (Dilantin), when was last level drawn Place rescue equipment at the bedside, including oxygen, oral airway, and suction equipment Establish IV or saline lock access for high risk clients Inspects the client's environment for items that may cause injury in the event of a seizure. Remove any unnecessary items from the immediate environment At the onset seizure, position the client for safety, and remain with client If sitting or standing, ease client to floor. Protect the client's head. If client is in bed, raise the side rails and pad for safety