a patient has developed a pressure ulcer what is the nurses priority intervention
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN

1. 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.

2. Which of the following is a critical nursing action when managing a patient with a chest tube?

Correct answer: B

Rationale: The correct answer is B: "Ensure the chest tube is connected to a closed drainage system." This is a critical nursing action when managing a patient with a chest tube because it is essential for proper drainage and to prevent complications such as air leaks or infections. Option A is incorrect because keeping the chest tube clamped at all times would prevent proper drainage and could lead to complications. Option C is incorrect as emptying the chest tube drainage system should be done based on assessment findings rather than a fixed time interval. Option D is incorrect because disconnecting the chest tube when the patient is ambulating can lead to complications like a pneumothorax.

3. A client is being taught about which foods to include in a low fiber diet. Which statement indicates understanding?

Correct answer: C

Rationale: The correct answer is C because white rice is a low-fiber food suitable for a low-fiber diet, making it an appropriate choice. Choices A, B, and D are incorrect because fresh pear, refried beans, and bran cereal are high-fiber foods and not suitable for a low-fiber diet.

4. When teaching a patient about self-administration of insulin, what is the most important instruction to provide?

Correct answer: A

Rationale: The most important instruction to provide when teaching a patient about self-administration of insulin is to rotate injection sites to prevent tissue damage. Rotating injection sites helps prevent lipodystrophy (tissue damage) and ensures proper insulin absorption. Option B is incorrect because the angle of insulin injection varies depending on the patient's body composition. Injecting at a 90-degree angle is not always necessary. Option C is not the most crucial instruction; while storing insulin in the refrigerator is important, it is not the priority when teaching self-administration. Option D is also important for maintaining consistency but is not as critical as rotating injection sites to prevent tissue damage.

5. A community health nurse is reviewing primary prevention strategies for West Nile virus with a group of clients in a rural health clinic. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct answer is B: 'Eliminate areas of standing water.' This is an essential primary prevention strategy for West Nile virus as it helps prevent the breeding of mosquitoes that spread the virus. Choices A, C, and D are incorrect. Avoiding exposure to deer ticks is more relevant for Lyme disease, using a respiratory mask when cleaning bird coops is not a primary prevention strategy for West Nile virus, and planning outdoor activities after dusk does not directly address the prevention of West Nile virus transmission.

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