a nurse is planning care for an older adult client who is at risk for developing pressure ulcers which of the following interventions should the nurse
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN

1. A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Correct answer: D

Rationale: The correct answer is to use a transfer device to lift the client up in bed. This intervention helps reduce friction and the risk of skin breakdown, aiding in the prevention of pressure ulcers. Elevating the head of the bed no more than 45 degrees can help with respiratory issues but does not directly address skin integrity. Applying cornstarch may lead to further skin irritation. Massaging over bony prominences can increase the risk of skin damage rather than maintaining skin integrity.

2. A nurse is caring for a newborn in the nursery following a circumcision. The newborn's grandparent, who does not have an identification bracelet, requests to take the newborn to his parents' room. Which of the following actions should the nurse take?

Correct answer: C

Rationale: In this scenario, where the grandparent lacks proper identification, the nurse should respectfully deny the request to take the newborn. It is crucial to prioritize the newborn's safety and security by following hospital policies and procedures. Checking the newborn's identification bracelet against the chart (Choice A) may not be sufficient to address the situation at hand, as the grandparent's lack of identification is the primary concern. While obtaining permission from the newborn's parents (Choice B) is important, the lack of proper identification from the grandparent takes precedence. Reviewing the newborn's footprints record (Choice D) is not necessary in this situation, as the immediate concern is ensuring proper identification and security before allowing the newborn to leave the nursery.

3. A healthcare professional is preparing to administer the initial dose of ceftriaxone to a client who has endometritis. Which of the following statements by the client should cause the healthcare professional to hold the medication and consult the provider?

Correct answer: A

Rationale: A severe allergy to amoxicillin could indicate a potential cross-reactivity with ceftriaxone, so the medication should be held. Cross-reactivity between penicillins (like amoxicillin) and cephalosporins (like ceftriaxone) is a known concern due to their similar chemical structures. Choices B, C, and D do not directly contraindicate the administration of ceftriaxone for endometritis.

4. A healthcare professional is assessing a patient's fluid balance. What is the most reliable indicator of fluid status?

Correct answer: B

Rationale: Checking the patient's weight daily is the most reliable indicator of fluid status because weight changes can directly reflect fluid retention or loss. Monitoring vital signs (Choice A) can provide some information but is not as specific as weight changes. Measuring intake and output (Choice C) is crucial but may not always accurately reflect fluid balance. Monitoring urine color (Choice D) can give some insights into hydration levels, but it is not as reliable as daily weight checks for assessing overall fluid status.

5. A patient is receiving enteral feedings through a nasogastric (NG) tube. What is the most appropriate nursing intervention?

Correct answer: B

Rationale: Checking the placement of the NG tube before each feeding is crucial as it ensures the tube is correctly positioned, reducing the risk of complications such as aspiration or improper delivery of feedings. Flushing the NG tube with water before and after each feeding can disrupt the feeding schedule and is not a standard procedure. Administering medications through the NG tube every 4 hours may not be necessary for all patients and should be based on specific medication requirements. Increasing the feeding rate without proper assessment and monitoring can lead to feeding intolerance or complications, making it an inappropriate intervention.

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