a nurse is caring for a client who is at risk for pressure injuries what intervention should the nurse implement
Logo

Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. A client at risk for pressure injuries is being cared for by a nurse. What intervention should the nurse implement?

Correct answer: B

Rationale: The correct intervention for a client at risk for pressure injuries is to use a special mattress. Special mattresses help reduce the risk of pressure injuries by redistributing pressure on bony areas, thus preventing tissue damage. Keeping the client in one position (choice A) can actually increase the risk of pressure injuries due to prolonged pressure on specific areas. Turning the client every 4 hours (choice C) is important for preventing pressure injuries, but using a special mattress is a more effective intervention. Providing extra pillows for positioning (choice D) may offer some comfort but does not address the primary intervention of pressure redistribution that a special mattress provides.

2. A client with diabetes mellitus has a foot ulcer. What is an appropriate intervention to promote wound healing?

Correct answer: B

Rationale: The correct answer is to apply a moisture-retentive dressing. This promotes a moist wound environment, which is crucial for wound healing in clients with diabetes. Encouraging a high-protein diet may support overall health but is not directly related to wound healing. Daily wound irrigation can disrupt the wound healing process by removing necessary growth factors and cells. Applying an ice pack to the wound is contraindicated as it can impair circulation and delay wound healing.

3. A client with diabetes mellitus is being taught about the importance of foot care by a nurse. Which instruction should the nurse include?

Correct answer: B

Rationale: The correct answer is B: 'Wear shoes at all times.' Clients with diabetes are at a higher risk of foot complications due to poor circulation and nerve damage. Wearing shoes at all times helps protect their feet from injuries. Choice A is incorrect because toenails should be cut straight across to prevent ingrown toenails. Choice C is incorrect as soaking feet in hot water can lead to burns or skin damage, especially for those with diabetes who may have reduced sensation. Choice D is incorrect because applying lotion between the toes can create a moist environment, increasing the risk of fungal infections.

4. A nurse is preparing to administer medications to a client through a nasogastric (NG) tube. Which action should the nurse take?

Correct answer: C

Rationale: The correct action for the nurse to take when administering medications through an NG tube is to dissolve each medication separately and flush with water between medications. This practice helps prevent interactions between medications and ensures that each medication is delivered effectively. Option A is incorrect as mixing all medications together can lead to chemical interactions or alter the effectiveness of the medications. Option B is incorrect because flushing the NG tube with air is not recommended and may cause harm. Option D is incorrect as administering all medications at the same time does not allow for proper absorption and interaction control.

5. A nurse is preparing to perform a routine abdominal assessment. Which action should the nurse take first?

Correct answer: B

Rationale: The correct answer is to auscultate bowel sounds. Auscultation should be performed before palpation during an abdominal assessment to avoid altering bowel sounds. Inspecting the abdomen is important but should follow auscultation. Percussion and palpation should be done after auscultation and inspection to ensure an accurate assessment.

Similar Questions

A nurse is assessing a client who reports a burning sensation at the site of a peripheral IV. The site is red and swollen. What is the nurse's priority action?
A nurse is reviewing the health history of a client who has a hip fracture. What risk factor should the nurse identify for developing pressure injuries?
A nurse is teaching about food choices for a client on a low-sodium diet. What food should the nurse recommend?
A nurse is assessing the IV infusion site of a client who reports pain at the site. The site is red, and there is warmth along the course of the vein. What should the nurse do?
A nurse is assessing a client who reports pain at the site of an indwelling urinary catheter. What is the nurse's first action?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses