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ATI FUNDAMENTALS ASSESSMENT GUIDE 2020,COMPLETE ANSWERS GRADED A.

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What points would the nurse discuss when teaching cane walking to a client for the first time? Two points of support should be used on the ground at all times. The cane should be used on the unaffected/stronger side and held with a firm grip. Bodyweight should be supported on both legs. The cane should be moved forward 15-25 cm (6-10 inches). After, the weaker leg should advance forward. Then, advance the stronger leg past the cane. A nurse is caring for a client with a blood pressure of 210/110. List the priority nursing interventions for this client. Assess for the cause of high blood pressure, such as kidney disease, hyperthyroidism, or medications. Administer prescribed medications that will decrease blood pressure. Assess for tachycardia, bradycardia pain, anxiety, and headache. Auscultate breath sounds and heart sounds. Assess skin color, temperature, and capillary refill time.

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