a nurse is caring for a client with diabetes mellitus who has a foot ulcer what is an appropriate intervention to promote wound healing
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Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. 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 type of dressing promotes a moist wound environment, which is crucial for wound healing. Applying a heating pad can lead to tissue damage, while daily wound irrigation can disrupt the wound healing process. Applying an ice pack is not recommended for promoting wound healing in this scenario.

2. A nurse is assessing a client who reports pain and tenderness at the site of an indwelling urinary catheter. What is the nurse's first action?

Correct answer: B

Rationale: The correct first action for the nurse to take when a client reports pain and tenderness at the site of an indwelling urinary catheter is to notify the provider. Pain and tenderness at the catheter site may indicate infection, and the healthcare provider needs to be informed for further assessment and appropriate interventions. Irrigating the catheter with normal saline (Choice A) should not be the initial action without consulting the provider first. While assessing for signs of infection (Choice C) is important, notifying the provider takes precedence. Administering prescribed antibiotics (Choice D) should only be done based on the provider's orders after assessment and confirmation of infection.

3. A nurse is caring for a client who has dementia and frequently tries to get out of bed. What actions should the nurse take? (Select all that apply)

Correct answer: C

Rationale: Maintaining the bed in the lowest position is an appropriate action when caring for a client with dementia who tries to get out of bed. This helps reduce the risk of falls and ensures the client's safety. Turning off the bed alarm (Choice A) is not advisable as it can be a safety measure to alert the staff when the client tries to get out of bed. Using physical restraints (Choice B) and applying a vest restraint (Choice D) should be avoided as they can lead to physical and psychological harm, reduce mobility, and compromise the client's dignity.

4. 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?

Correct answer: B

Rationale: Corrected Rationale: Poor nutrition increases the risk of developing pressure injuries as it impairs skin integrity and healing. Frequent repositioning, increased fluid intake, and the use of a special mattress are all important interventions for preventing pressure injuries, rather than risk factors for developing them. Repositioning helps relieve pressure, adequate fluid intake maintains skin hydration, and special mattresses redistribute pressure to prevent injuries.

5. A healthcare provider is assessing the pain level of a client who has dementia and difficulty communicating. Which pain assessment technique should the healthcare provider use?

Correct answer: C

Rationale: In clients with dementia and difficulty communicating, using behavioral indicators such as agitation and restlessness is more reliable for assessing pain than relying on verbal self-report, pain scales, or observing facial expressions. Verbal self-report may not be possible due to communication challenges, pain scales may be difficult for the client to comprehend, and observing facial expressions alone may not provide a comprehensive assessment of pain in individuals with dementia.

Similar Questions

A healthcare provider is performing a cultural assessment of a group of clients to maintain respect for their value systems and beliefs. Which of the following should the provider identify as examples of cultural variables?
A healthcare professional is reviewing the health history of a client who has a hip fracture. What is a risk factor for developing pressure injuries?
A nurse is assessing a client who reports a burning sensation at the site of a peripheral IV. The site is red and warm. What should the nurse do?
A client with diabetes mellitus is receiving discharge instructions about foot care from a nurse. Which statement indicates an understanding of the teaching?
A nurse is caring for a client who is receiving continuous enteral feedings. What finding indicates intolerance to the feeding?

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