a nurse is reviewing the notes from a previous shift and finds incomplete documentation what is the most appropriate action
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN

1. While reviewing notes from a previous shift, a nurse finds incomplete documentation. What is the most appropriate action?

Correct answer: B

Rationale: The most appropriate action when finding incomplete documentation is to notify the nurse manager of the issue. This ensures that accurate records are maintained and the situation can be addressed properly. Completing the missing documentation on behalf of someone else may lead to inaccuracies, asking the nurse to complete it may not guarantee timely correction, and confronting the nurse could create a confrontational situation that is not conducive to effective teamwork.

2. What is the nurse's priority intervention for a patient who has developed a pressure ulcer?

Correct answer: B

Rationale: The correct answer is to reposition the patient every 2 hours. Repositioning helps prevent the worsening of pressure ulcers by relieving pressure on affected areas and promoting blood circulation, which aids in healing. Applying a dressing (choice A) is important but not the priority compared to repositioning. Providing pain medication (choice C) is essential for comfort but does not address the root cause of the pressure ulcer. Cleaning the ulcer with normal saline (choice D) is part of wound care but does not take precedence over repositioning to prevent further tissue damage.

3. A nurse is observing a nursing student practicing standard precautions. Which observation by the instructor indicates that further teaching is necessary?

Correct answer: D

Rationale: The correct answer is D because touching a patient's skin with sterile gloves compromises the sterility of the gloves, increasing the risk of contamination. Choices A, B, and C demonstrate correct practices in standard precautions. Wearing gloves when changing bed linens and to remove a wound dressing, as well as washing hands after removing gloves, are all appropriate and necessary steps to prevent the spread of infection.

4. When caring for a patient with a colostomy, which nursing action is most important?

Correct answer: B

Rationale: Emptying the colostomy bag when it is half full is the most important nursing action when caring for a patient with a colostomy. This practice helps prevent leakage, reduces the risk of skin irritation, and promotes patient comfort. Monitoring for signs of infection (Choice A) is essential but not as crucial as maintaining proper colostomy care. Encouraging the patient to eat smaller, more frequent meals (Choice C) can be beneficial for colostomy patients but is not as critical as ensuring timely emptying of the colostomy bag. Applying a skin barrier to prevent irritation (Choice D) is important, but ensuring timely emptying of the colostomy bag takes precedence in preventing complications associated with a colostomy.

5. A nurse is assessing a client with diabetes who reports frequent episodes of hypoglycemia. What should the nurse recommend to prevent these episodes?

Correct answer: B

Rationale: The correct recommendation to prevent hypoglycemic episodes in a client with diabetes who reports frequent episodes is to monitor blood glucose levels frequently. By monitoring blood glucose levels, the nurse can make necessary adjustments to insulin dosage and diet to maintain blood sugar levels within the target range. Increasing protein intake (Choice A) is not directly related to preventing hypoglycemia; it is more important to focus on balancing carbohydrates and insulin. Increasing the dose of insulin (Choice C) without proper monitoring can lead to further hypoglycemic episodes. Similarly, reducing carbohydrate intake (Choice D) should be done cautiously as carbohydrates are a main source of energy and sudden reduction can cause hypoglycemia in diabetic patients.

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