a nurse is developing a care plan for a client who has paraplegia and has an area of nonblanchable erythema over the ischium which intervention should

ATI RN

ATI Exit Exam 2023

1. A nurse is developing a care plan for a client who has paraplegia and has an area of nonblanchable erythema over the ischium. Which intervention should the nurse include?

A. Place the client upright on a donut-shaped cushion.
B. Teach the client to shift his weight every 15 minutes while sitting.
C. Turn and reposition the client every 3 hours.
D. Assess pressure points every 24 hours.

Correct answer: B

Rationale: The correct intervention for a client with nonblanchable erythema over the ischium is to teach the client to shift his weight every 15 minutes while sitting. This action helps relieve pressure on the affected area and prevents further skin breakdown. Placing the client upright on a donut-shaped cushion (Choice A) may not address the need for frequent weight shifts. Turning and repositioning the client every 3 hours (Choice C) is important for overall skin health but may not provide adequate relief for the specific area of nonblanchable erythema. Assessing pressure points every 24 hours (Choice D) is not frequent enough to prevent worsening of the skin condition in this case.

2. A client with diabetes mellitus is receiving teaching from a nurse about foot care. Which of the following instructions should the nurse include?

A. Soak your feet in warm water daily.
B. Wear cotton socks.
C. Use a heating pad to warm your feet.
D. Trim toenails straight across.

Correct answer: D

Rationale: The correct answer is to trim toenails straight across. This instruction is crucial for clients with diabetes to prevent ingrown toenails, which can lead to infection. Soaking feet in warm water daily can increase the risk of skin breakdown. Cotton socks are recommended, but the priority in foot care for diabetes is proper nail trimming. Using a heating pad can also pose a burn risk for individuals with reduced sensation in their feet.

3. How should a healthcare provider manage a patient with chronic pain?

A. Administer analgesics
B. Encourage physical activity
C. Administer non-pharmacological interventions
D. Encourage deep breathing exercises

Correct answer: A

Rationale: Administering prescribed analgesics is a crucial aspect of managing chronic pain effectively. Analgesics help alleviate pain symptoms and improve the patient's quality of life. While physical activity and non-pharmacological interventions can also play a role in pain management, the immediate need for relief in chronic pain often requires pharmacological intervention. Encouraging deep breathing exercises may provide some relief in certain situations, but it may not be as effective as analgesics for managing chronic pain.

4. Which lab value should be monitored for a patient on warfarin therapy?

A. Monitor INR
B. Monitor potassium levels
C. Monitor platelet count
D. Monitor sodium levels

Correct answer: A

Rationale: The correct answer is to monitor INR for a patient on warfarin therapy. INR monitoring is crucial as it helps assess the therapeutic effectiveness and safety of warfarin. INR stands for International Normalized Ratio, and it measures the blood's ability to clot. Monitoring potassium levels (Choice B) is not specific to warfarin therapy. Monitoring platelet count (Choice C) is important but not the primary lab value for assessing warfarin therapy. Monitoring sodium levels (Choice D) is not directly related to warfarin therapy.

5. A nurse is caring for a client who is postoperative following a craniotomy. Which of the following findings indicates the client is developing diabetes insipidus?

A. Polyuria
B. Hypertension
C. Bradycardia
D. Hyperglycemia

Correct answer: A

Rationale: Polyuria is the correct finding indicating the client is developing diabetes insipidus. Diabetes insipidus is characterized by the excretion of large volumes of diluted urine due to a deficiency in antidiuretic hormone. This results in increased urine output (polyuria) despite adequate fluid intake. Hypertension (choice B) is not typically associated with diabetes insipidus but can be seen in other conditions. Bradycardia (choice C) and hyperglycemia (choice D) are also not typical findings of diabetes insipidus.