a client with type 2 diabetes mellitus presents to the clinic with a foot ulcer which instruction should the nurse provide to the client to promote he
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Nursing Elites

ATI LPN

ATI PN Adult Medical Surgical 2019

1. A client with type 2 diabetes mellitus presents to the clinic with a foot ulcer. Which instruction should the nurse provide to the client to promote healing of the ulcer?

Correct answer: C

Rationale: The correct answer is C: "Keep the ulcer clean and dry." For clients with diabetes mellitus, it is crucial to maintain foot ulcers clean and dry to prevent infection and promote healing. Moist environments can lead to bacterial growth and delay healing. Applying a heating pad (Choice A) can increase the risk of burns and further damage the ulcer. Wearing tight-fitting shoes (Choice B) can cause friction and pressure on the ulcer, hindering the healing process. Limiting walking (Choice D) excessively can affect circulation and delay healing. Therefore, the nurse should instruct the client to keep the ulcer clean and dry for optimal wound care management.

2. A male client is admitted to the neurological unit. He has just sustained a C-5 spinal cord injury. Which assessment finding of this client warrants immediate intervention by the nurse?

Correct answer: D

Rationale: Respirations that are shallow, labored, and at 14 breaths/minute indicate potential respiratory compromise, which is a critical situation requiring immediate intervention to maintain adequate oxygenation and prevent respiratory failure.

3. The community mental health nurse is planning to visit four clients with schizophrenia today. Which client should the nurse see first?

Correct answer: A

Rationale: The mother who took her children from school due to delusions of aliens poses a significant risk to her children and herself. This situation requires immediate attention to ensure the safety and well-being of all involved. Choice B is concerning due to the history of substance abuse, but the immediate risk to life and safety as in Choice A takes precedence. Choice C, although important, does not present an immediate danger as the delusional belief of aliens. Choice D, while emotionally distressing, does not pose an immediate threat as the situation described in Choice A.

4. A client with rheumatoid arthritis is prescribed methotrexate. Which instruction should the nurse include in the client's teaching?

Correct answer: A

Rationale: The correct instruction for the client prescribed with methotrexate is to avoid alcohol while taking this medication. Methotrexate can cause liver toxicity, and alcohol consumption can further exacerbate this risk. It is crucial for patients to abstain from alcohol to prevent adverse effects on the liver. Therefore, instructing the client to avoid alcohol is a key component of safe medication use and management of rheumatoid arthritis.

5. During an admission physical assessment, the nurse is examining a newborn who is small for gestational age (SGA). Which finding should the nurse report immediately to the pediatric healthcare provider?

Correct answer: C

Rationale: A widened, tense, bulging fontanel is a critical finding in a newborn as it can indicate increased intracranial pressure. This condition requires immediate attention and intervention to prevent further complications. Monitoring fontanel status is crucial in assessing the newborn's neurological well-being and ensuring early detection of potential issues.

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