a nurse is documenting client care which entry should the nurse identify as an example of the implementation of client care
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Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. While documenting client care, which entry should the nurse identify as an example of implementing client care?

Correct answer: D

Rationale: The correct answer is D because contacting the provider to report client findings is an example of implementing care. Implementation involves putting the care plan into action based on assessment data. While options A, B, and C are important aspects of client care, they mainly focus on assessment rather than the actual implementation of care.

2. A client with a new diagnosis of diabetes mellitus is being taught about foot care. What instruction should the nurse include?

Correct answer: B

Rationale: The correct answer is to wear shoes at all times. This instruction is vital for clients with diabetes mellitus as it helps protect the feet and reduces the risk of injury. Option A is incorrect as applying lotion between the toes can increase moisture and the risk of fungal infections. Option C is incorrect as cutting toenails in a rounded shape may lead to ingrown toenails. Option D is also incorrect as inspecting the feet weekly is not sufficient for proper foot care in clients with diabetes mellitus.

3. 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?

Correct answer: B

Rationale: Urinary incontinence is a risk factor for developing pressure injuries as it can lead to skin breakdown due to constant exposure to moisture and irritation. Increased fluid intake is important for hydration and overall health but is not directly linked to pressure injuries. Poor nutrition can impair wound healing but is not a direct risk factor for pressure injuries. Immobility can contribute to the development of pressure injuries but is not as directly related as urinary incontinence.

4. A nurse is providing discharge teaching to a client with a new diagnosis of hypertension. What lifestyle modification should the nurse emphasize?

Correct answer: B

Rationale: The correct lifestyle modification that the nurse should emphasize for a client with hypertension is to increase fluid intake to 2 liters per day. Proper hydration helps manage hypertension by supporting kidney function in regulating blood pressure and by diluting sodium levels in the body. Decreasing potassium intake (Choice A) is not recommended, as potassium-rich foods like fruits and vegetables are beneficial for blood pressure control. Avoiding foods high in calcium (Choice C) is not directly related to managing hypertension, and increasing sodium intake (Choice D) is contraindicated as excess sodium can elevate blood pressure.

5. A charge nurse discovers that a nurse did not notify the provider that a client's condition had changed. The charge nurse should identify that the nurse is accountable for which of the following torts?

Correct answer: A

Rationale: The correct answer is A: Negligence. Negligence in nursing occurs when a healthcare provider fails to take appropriate action that a reasonably prudent provider would take in a similar situation, such as not notifying the provider of changes in a client's condition. In this scenario, the nurse's failure to inform the provider of the client's changed condition constitutes negligence. Choices B, C, and D are incorrect. Assault involves the intentional threat of bodily harm to another person, battery is the intentional harmful or offensive touching of another person without their consent, and defamation is the act of making false statements about someone to a third party that harms that person's reputation.

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