a community health nurse is teaching a group of clients about first aid for different types of wounds which client statement indicates an understandin
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Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. A community health nurse is teaching a group of clients about first aid for different types of wounds. Which client statement indicates an understanding of the teaching?

Correct answer: C

Rationale: The correct answer is C because placing a clean dressing over the saturated one helps maintain wound integrity and prevents further tissue damage. Choice A is incorrect as applying direct pressure to the wound is correct for controlling bleeding but not for dressing changes. Choice B is incorrect because removing dressings may disrupt wound healing and increase the risk of infection. Choice D is incorrect since applying alcohol to the wound can cause further irritation and damage to the tissues.

2. A charge nurse is making assignments for the upcoming shift. Which client should the charge nurse assign to a licensed practical nurse (LPN)?

Correct answer: C

Rationale: The correct answer is C because a client with dehydration and inflammatory bowel disease is stable enough for care by an LPN. This condition does not require complex interventions that would necessitate a higher level of nursing care. Choice A is incorrect as administering IV antibiotics for pneumonia requires a higher level of nursing expertise. Choice B is incorrect because monitoring for dehydration may involve assessing vital signs and making critical decisions. Choice D is incorrect as providing care for surgical wound care involves wound assessment, dressing changes, and monitoring for signs of infection, which typically require a registered nurse.

3. While assessing the IV infusion site of a client experiencing pain, redness, and warmth, what should the nurse do?

Correct answer: B

Rationale: The correct answer is to discontinue the infusion. Pain, redness, and warmth at the IV site are signs of phlebitis, which is inflammation of the vein. Continuing the infusion can further irritate the vein and lead to complications. Increasing the IV flow rate would exacerbate the issue by delivering more irritants to the vein. Elevating the limb and applying a cold compress are not the appropriate interventions for phlebitis, as discontinuing the infusion is crucial to prevent further harm.

4. A nurse in an acute care facility is caring for a client who is postop following abdominal surgery. Which behavior should the nurse identify as increasing the client's risk for constipation?

Correct answer: B

Rationale: Frequent urge suppression can lead to constipation, especially postoperatively. Suppressing the urge to defecate can disrupt normal bowel movements and result in constipation. Increased physical activity, increased fiber intake, and adequate fluid intake are measures that typically help prevent constipation by promoting bowel regularity and preventing stool hardening. Therefore, choices A, C, and D are not behaviors that increase the client's risk for constipation.

5. A nurse receives a report from assistive personnel that a client's BP is 160/95. What should the nurse do first?

Correct answer: B

Rationale: The correct first action for the nurse to take when receiving a report of a client's blood pressure reading of 160/95 is to recheck the blood pressure. Rechecking the blood pressure ensures the accuracy of the reading before making any further decisions or interventions. Notifying the provider (Choice A) can be considered after confirming the blood pressure reading. Administering antihypertensive medication (Choice C) should not be done based solely on one reading without verification. Documenting the blood pressure in the chart (Choice D) should also come after confirming the accuracy of the reading to avoid recording incorrect information.

Similar Questions

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A nurse is preparing to administer enteral feedings to a client with a nasogastric (NG) tube. What action should the nurse take first?
A client with diabetes mellitus has a foot ulcer. What is an appropriate intervention to promote wound healing?
A nurse is teaching a group of assistive personnel about expected integumentary changes in older adults. What change should the nurse include?

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