a nurse is planning care for a client who has a stage 3 pressure injury which of the following interventions should the nurse include in the plan
Logo

Nursing Elites

ATI RN

ATI RN Comprehensive Exit Exam

1. A client has a stage 3 pressure injury. Which of the following interventions should the nurse include in the plan?

Correct answer: D

Rationale: The correct intervention for a client with a stage 3 pressure injury is to apply a moisture barrier ointment. This helps protect the skin, maintain moisture balance, and promote healing. Choice A is incorrect because povidone-iodine solution can be too harsh for wound care. Choice B is incorrect as hydrogen peroxide can be cytotoxic to healing tissue. Choice C is important for preventing pressure injuries but is not a direct intervention for a stage 3 wound.

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

Correct answer: B

Rationale: The correct answer is B: Apply a hydrocolloid dressing. Applying a hydrocolloid dressing helps create a moist environment that promotes healing in clients with stage 2 pressure injuries. Choice A, cleansing the wound with povidone-iodine, is not recommended for stage 2 pressure injuries as it can be too harsh on the skin. Performing debridement as needed, as mentioned in choice C, is not typically indicated for stage 2 pressure injuries, which involve partial-thickness skin loss. Keeping the wound open to air, as stated in choice D, is also not the preferred approach for managing stage 2 pressure injuries, as maintaining a moist environment is key to promoting healing.

3. Which lab value should be monitored in patients receiving heparin therapy?

Correct answer: A

Rationale: The correct answer is to monitor aPTT in patients receiving heparin therapy. Activated Partial Thromboplastin Time (aPTT) is crucial to assess the therapeutic effectiveness of heparin and to prevent bleeding complications. Monitoring INR (Choice B) is more relevant for patients on warfarin therapy, not heparin. Platelet count (Choice C) monitoring is essential for detecting heparin-induced thrombocytopenia rather than assessing heparin therapy itself. Monitoring sodium levels (Choice D) is not directly related to heparin therapy monitoring.

4. A nurse is assessing a client who has a urinary tract infection and is receiving ciprofloxacin. Which of the following findings should the nurse report to the provider?

Correct answer: B

Rationale: The correct answer is B: Photosensitivity. Ciprofloxacin can cause photosensitivity, making the client more sensitive to sunlight. It is essential for the nurse to report this finding to the provider so that appropriate measures can be taken to prevent skin damage. Dry mouth, headache, and urinary retention are not typically associated with ciprofloxacin use and do not require immediate reporting to the provider in this scenario.

5. A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following instructions should the nurse include?

Correct answer: A

Rationale: The correct instruction the nurse should include is to advise the client to avoid consuming foods high in vitamin K. Foods rich in vitamin K, such as leafy greens, can interfere with the effectiveness of warfarin, an anticoagulant medication. Therefore, it is important for clients on warfarin therapy to maintain consistent vitamin K intake to keep their INR levels stable. The other options are also important but not the priority in the context of warfarin therapy. Ingesting foods high in vitamin K can affect the medication's efficacy, making it crucial to highlight this dietary consideration during client education.

Similar Questions

A healthcare professional is reviewing the laboratory results of a client who is receiving chemotherapy. Which of the following findings should the healthcare professional report immediately?
A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations. The client states, 'It's hard not to listen to the voices.' Which of the following questions should the nurse ask?
Which medication is commonly used to treat hyperthyroidism?
What is the most important nursing action for a patient presenting with confusion after surgery?
A nurse is preparing to administer a rectal suppository to a client. What action should the nurse take?

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