a nurse is reviewing the health history of a client who has a hip fracture what risk factor should the nurse identify for developing pressure injuries
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Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. A nurse is reviewing the health history of a client who has a hip fracture. What risk factor should the nurse identify for developing pressure injuries?

Correct answer: B

Rationale: Corrected Rationale: Poor nutrition increases the risk of developing pressure injuries as it impairs skin integrity and healing. Frequent repositioning, increased fluid intake, and the use of a special mattress are all important interventions for preventing pressure injuries, rather than risk factors for developing them. Repositioning helps relieve pressure, adequate fluid intake maintains skin hydration, and special mattresses redistribute pressure to prevent injuries.

2. When admitting a client with meningococcal meningitis, what should the nurse do first?

Correct answer: B

Rationale: When admitting a client with meningococcal meningitis, the nurse's priority should be to place the client on droplet precautions. This is crucial to prevent the spread of the infection to others. Administering antibiotics, performing a lumbar puncture, and initiating seizure precautions are important interventions but should come after implementing droplet precautions to ensure the safety of both the client and others.

3. A client has a new prescription for a metered-dose inhaler (MDI). What instruction should the nurse include?

Correct answer: C

Rationale: The correct instruction for a client using a metered-dose inhaler (MDI) is to hold the inhaler 1-2 inches from the mouth. This distance allows for the proper delivery of the medication into the lungs. Choice A is incorrect because the duration of inhalation can vary depending on the medication, and 1 second may not be adequate. Choice B is incorrect as shaking the inhaler vigorously is not necessary for all MDIs and can lead to inaccurate dosing. Choice D is incorrect as the client should hold their breath for about 10 seconds after inhalation to allow the medication to deposit in the lungs.

4. A nurse is caring for a client who is postop following abdominal surgery. What behavior should the nurse identify as increasing the client's risk for constipation?

Correct answer: B

Rationale: The correct answer is B: Decreased physical activity. Following abdominal surgery, reduced physical activity can contribute to constipation due to decreased bowel motility. Increased fiber intake (choice A) generally helps prevent constipation by adding bulk to the stool. Frequent urge suppression (choice C) may lead to issues like urinary retention but is not directly linked to constipation. Adequate sleep (choice D) is important for overall recovery but does not significantly impact constipation risk.

5. A healthcare professional is planning to administer an intramuscular injection to a client. What muscle should the healthcare professional choose to avoid injury?

Correct answer: B

Rationale: The ventrogluteal muscle is the preferred site for intramuscular injections to avoid injury. Choosing the ventrogluteal site reduces the risk of injury to major nerves and blood vessels, unlike the deltoid, rectus femoris, or dorsogluteal sites. The deltoid muscle is commonly used for vaccines but has a higher risk of injury due to its proximity to the radial nerve. The rectus femoris muscle is not recommended for intramuscular injections due to its location and the risk of injury. The dorsogluteal site is also not recommended as it poses a risk of injury to the sciatic nerve and superior gluteal artery.

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