a nurse is caring for a client with a stage 2 pressure ulcer define the characteristics of the ulcer
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 B with NGN

1. A nurse is caring for a client with a stage 2 pressure ulcer. Define the characteristics of the ulcer.

Correct answer: C

Rationale: The correct answer is C. Stage 2 ulcers involve partial-thickness skin loss with visible and superficial damage, which may appear as an abrasion, blister, or shallow crater. Choice A describes a Stage 1 pressure ulcer characterized by intact skin with nonblanchable redness. Choice B describes a Stage 3 pressure ulcer with full-thickness tissue loss and damage to the subcutaneous tissue. Choice D is indicative of a Stage 4 pressure ulcer, involving full-thickness tissue loss with damage extending to muscle or bone.

2. Four clients present to the emergency department. The nurse should plan to see which of the following clients first?

Correct answer: D

Rationale: The correct answer is D. The client with slurred speech and a headache may be experiencing a stroke, which is a medical emergency that requires immediate attention to prevent irreversible brain damage. While each client requires prompt assessment and care, the priority is to address potentially life-threatening conditions first. Choices A, B, and C, although important, do not present with symptoms as critical as those of a possible stroke, which necessitates urgent intervention.

3. A nurse is planning to delegate to an AP the task of fasting blood glucose testing for a client who has diabetes mellitus. Which of the following actions should the nurse take?

Correct answer: A

Rationale: Before delegating any task, the nurse must determine whether the AP is qualified to perform it. In this scenario, verifying the AP's competency to conduct fasting blood glucose testing is crucial for patient safety and compliance with facility protocols. The other choices are incorrect because they do not address the essential step of assessing the AP's ability to perform the delegated task. While helping the AP or assigning tasks related to diabetic medication or medical records are important, the primary concern should be confirming the AP's competence for the specific delegated duty of blood glucose testing.

4. A client with ulcerative colitis has a new prescription for sulfasalazine. What adverse effect should the client monitor for according to the nurse?

Correct answer: A

Rationale: The correct answer is A: Jaundice. Sulfasalazine can lead to liver toxicity, making it essential to monitor for jaundice, a sign of liver dysfunction. Choices B, C, and D are incorrect because constipation, oral candidiasis, and sedation are not commonly associated with sulfasalazine use.

5. A nurse is providing discharge instructions about breast engorgement to a client who has decided not to breastfeed. Which of the following statements by the client indicates a need for further instruction?

Correct answer: C

Rationale: The correct answer is C. Manually expressing breast milk will stimulate more milk production, which contradicts the goal of reducing milk supply in clients who choose not to breastfeed. Choices A, B, and D are correct statements that can help relieve breast engorgement without promoting further milk production.

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