a nurse is managing a client with a wound infection what is the priority action
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2020 Answers

1. A healthcare professional is managing a client with a wound infection. What is the priority action?

Correct answer: B

Rationale: Performing a wound culture before applying antibiotics is crucial to identify the specific pathogen causing the infection. This helps in selecting the most effective antibiotics for treatment. Changing the wound dressing, applying a wet-to-dry dressing, or cleansing the wound are important interventions but should follow the assessment and identification of the infecting organism through a wound culture to guide appropriate treatment.

2. When instructing a client with tuberculosis on home care, what is the priority teaching point?

Correct answer: C

Rationale: The correct answer is C: 'Take medication for 6-9 months.' The priority teaching point for a client with tuberculosis is to ensure they understand the importance of completing the entire course of medication. This is crucial to effectively treat and cure tuberculosis, prevent the development of drug-resistant strains, and reduce the risk of transmission to others. Choice A is incorrect as wearing a surgical mask at all times is not the priority teaching point for tuberculosis home care. Choice B is not the priority teaching point; while limiting visitors can help reduce exposure to others, completing the medication course is more critical. Choice D is not relevant to tuberculosis home care instructions.

3. A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client's safety while walking in the halls, the nurse should do which of the following?

Correct answer: B

Rationale: Assessing the client's gait for steadiness is the most appropriate action to ensure the safety of a client with dementia while walking. This allows the nurse to identify any issues that may increase the risk of falls or accidents. Administering PRN haloperidol or lorazepam is not indicated as the first-line approach in managing wandering behavior and can have adverse effects like increased risk of falls, confusion, or oversedation. Restraint use should be avoided whenever possible, as it can lead to physical and psychological harm to the client.

4. A nurse is caring for a client who is scheduled for a bronchoscopy. Which of the following findings should the nurse report to the provider?

Correct answer: D

Rationale: The correct answer is D. A platelet count of 100,000/mm³ is low and increases the risk of bleeding during the bronchoscopy. This finding should be reported to the provider for further evaluation and possible intervention. Choices A, B, and C are not as critical in this situation. Anxiety about the procedure is common and can be managed with appropriate interventions. Not eating for 8 hours is a standard pre-procedure requirement to prevent aspiration during sedation. A reported allergy to shellfish is important to note but is not directly related to the risk of complications during a bronchoscopy.

5. What are the common causes of postoperative pain and how should it be managed?

Correct answer: A

Rationale: Postoperative pain is commonly caused by the surgical incision and muscle tension. The correct answer is A. Surgical incisions cause tissue damage, triggering pain responses. Muscle tension can result from factors like positioning during surgery or guarding due to pain. Managing postoperative pain caused by surgical incisions and muscle tension involves the use of analgesics to alleviate discomfort. Choices B, C, and D are incorrect. Nerve damage and wound complications may also cause pain but are not as common as surgical incisions and muscle tension. Hypotension and respiratory issues are not direct causes of postoperative pain. Infection at the incision site can lead to pain, but it is a specific complication rather than a common cause of postoperative pain.

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