a nurse is planning care for a client who has a stage 2 pressure injury which of the following interventions should the nurse include in the plan
Logo

Nursing Elites

ATI RN

ATI RN Comprehensive Exit Exam 2023

1. A nurse is planning care for a client who has a stage 2 pressure injury. Which of the following interventions should the nurse include in the plan?

Correct answer: D

Rationale: The correct answer is to apply a hydrocolloid dressing. For a stage 2 pressure injury, maintaining a moist environment is crucial for healing. Hydrocolloid dressings help achieve this by promoting autolytic debridement and creating a barrier against bacteria while allowing the wound to heal. Applying a dry dressing (Choice A) may not provide the necessary moisture for healing. Cleansing the wound with normal saline (Choice B) is essential, but a hydrocolloid dressing is more specific for promoting healing in this case. Performing debridement as needed (Choice C) is not typically indicated for stage 2 pressure injuries, as they involve partial-thickness skin loss without slough or eschar.

2. A nurse is reviewing the medical records of a client with chronic heart failure. What dietary recommendation should the nurse make?

Correct answer: A

Rationale: The correct answer is A: Follow a 3g sodium diet. For clients with chronic heart failure, limiting sodium intake is crucial to prevent fluid retention and exacerbation of heart failure symptoms. High sodium intake can lead to fluid buildup, causing the heart to work harder. Choices B, C, and D are incorrect. Drinking excessive fluid can worsen fluid retention in heart failure, elevating the workload of the heart. Placing the client's lower extremities on two pillows is a positioning intervention to alleviate edema, not a dietary recommendation. Maintaining oxygen saturation at 89% is more related to respiratory status rather than dietary management of chronic heart failure.

3. A client is receiving continuous IV nitroprusside for severe hypertension. Which action should the nurse take?

Correct answer: C

Rationale: The correct action for the nurse to take is to limit IV exposure to light. Nitroprusside is light-sensitive, and exposure to light can lead to its degradation, potentially reducing its efficacy in treating severe hypertension. Keeping calcium gluconate at the bedside (Choice A) is not directly related to managing nitroprusside infusion. While monitoring blood pressure every 2 hours (Choice B) is important in managing hypertension, it is not the immediate action required to ensure medication efficacy. Attaching an inline filter to the IV tubing (Choice D) may help filter particles but does not address the critical concern of light sensitivity associated with nitroprusside administration.

4. A nurse is caring for a client who is 2 hr postoperative following an inguinal hernia repair. Which of the following findings should the nurse report to the provider?

Correct answer: D

Rationale: A low urine output of 20 mL/hr, less than the expected 30 mL/hr or more, could indicate renal impairment or inadequate fluid status postoperatively. In this scenario, early detection and intervention are crucial to prevent further complications. The other findings - heart rate of 88/min, pain rating of 4, and blood pressure of 110/70 mm Hg - are within normal limits for a client 2 hr postoperative following an inguinal hernia repair and do not raise immediate concerns.

5. A client with iron deficiency anemia has a new prescription for ferrous sulfate. Which of the following instructions should the nurse include?

Correct answer: C

Rationale: The correct instruction is to take ferrous sulfate on an empty stomach to increase absorption. This is because taking it with food or dairy products like milk can reduce its absorption. Orange juice is not recommended as it may interfere with the absorption of iron. Taking ferrous sulfate on an empty stomach may cause gastrointestinal upset, but this can be minimized by gradually increasing the dose.

Similar Questions

A nurse is providing discharge teaching to a client who is postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include?
How should a healthcare professional care for a patient with a stage 2 pressure ulcer?
A nurse is planning care for a school-age child who is 4 hours postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?
A nurse is assessing a client with a history of post-traumatic stress disorder (PTSD). Which of the following findings should the nurse expect?
Which electrolyte imbalance is commonly seen in patients taking furosemide?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses