a nurse is teaching a client about signs of infection after surgery what statement indicates further teaching is required
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN

1. A nurse is teaching a client about signs of infection after surgery. What statement indicates further teaching is required?

Correct answer: B

Rationale: The correct answer is B. Any drainage from the incision site should be monitored, and any signs of infection, such as increased redness or warmth, need to be reported to the healthcare provider. Choices A, C, and D provide accurate information about signs of infection after surgery and do not indicate a need for further teaching.

2. A healthcare professional is reviewing the medical records of a client who has a pressure ulcer. Which of the following findings should the professional expect?

Correct answer: A

Rationale: The correct answer is A: Albumin level of 3. A low albumin level indicates poor nutrition, which can contribute to the development of pressure ulcers. Choice B, Hemoglobin of 12, is within the normal range and is not directly associated with pressure ulcers. Choice C, Normal skin moisture, does not provide specific information related to pressure ulcers. Choice D, No signs of infection, while important, is not a direct finding associated with pressure ulcers.

3. A patient is experiencing shortness of breath. What is the nurse's immediate action?

Correct answer: B

Rationale: Administering oxygen at 2 liters per minute via nasal cannula is the immediate action for a patient experiencing shortness of breath. This intervention helps to improve oxygenation and relieve respiratory distress promptly. Placing the patient in a high Fowler's position (choice A) may also be beneficial but providing oxygen takes precedence in this scenario to address the underlying hypoxemia. Encouraging deep breaths and coughing (choice C) may not be appropriate as the first action, especially without assessing the patient first. Assessing lung sounds (choice D) is essential but should follow the initial intervention of administering oxygen.

4. Which action by the nurse will help prevent ventilator-associated pneumonia (VAP) in a patient on mechanical ventilation?

Correct answer: A

Rationale: The correct answer is A. Providing oral care every 4 hours helps prevent ventilator-associated pneumonia by reducing the buildup of bacteria in the mouth that can be aspirated into the lungs. Repositioning the patient every 2 hours is important for preventing pressure ulcers but is not directly related to preventing VAP. Suctioning the patient as needed is essential for maintaining airway patency but does not specifically prevent VAP. Administering antibiotics as prescribed is a treatment for infections but does not prevent VAP.

5. A client is undergoing chemotherapy and expresses concern about hair loss. What is the best response?

Correct answer: D

Rationale: The best response when a client undergoing chemotherapy expresses concern about hair loss is to advise them that chemotherapy causes temporary hair loss. This response provides accurate information to the client about the side effect they are experiencing. Choice A is incorrect because it may provide false reassurance as for some individuals, hair loss can be a challenging experience. Choice B is not the best initial response as addressing the client's concerns and providing information should come first. Choice C is not the most appropriate response as cutting hair short may not necessarily prevent hair loss and does not address the client's concerns about the temporary nature of chemotherapy-induced hair loss.

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