an incontinent elderly client frequently wets his bed and eventually develop redness and skin excoriation at the perianal area the best nursing goal f
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Nursing Elites

ATI RN

ATI Proctored Nutrition Exam 2019

1. For an incontinent elderly client who frequently wets his bed and develops redness and skin excoriation at the perianal area, what is the best nursing goal?

Correct answer: A

Rationale: The best nursing goal for an incontinent elderly client with skin excoriation is to ensure that the bed linen is always dry. This helps in preventing further skin breakdown and promoting skin integrity. Choice B, to frequently check the bed for wetness and keep it dry, may not address the issue of prevention if the linen is not consistently dry. Choice C, placing a rubber sheet under the client's buttocks, focuses more on protecting the mattress rather than addressing the client's skin condition directly. Choice D, keeping the patient clean and dry, is important but does not specifically address the preventive aspect of maintaining dry bed linen.

2. Why is a pulse oximeter attached to Mr. Dizon's finger?

Correct answer: D

Rationale: A pulse oximeter is used to detect the oxygen saturation levels in arterial blood before the onset of hypoxemia symptoms. This device provides essential information about the effectiveness of oxygen transportation to the body's tissues. Choice A is incorrect because a pulse oximeter does not directly measure hemoglobin levels nor determine the need for a blood transfusion. Choice B is incorrect because a pulse oximeter is designed specifically to assess oxygen saturation, not tissue perfusion. Choice C is incorrect because a pulse oximeter is not used to measure the efficacy of anti-hypertensive medications, but rather to monitor oxygen levels in the blood.

3. Which of the following has the greatest effect on an increase in body weight?

Correct answer: D

Rationale: Total kilocalories have the greatest effect on body weight as they represent the overall energy intake from all macronutrients combined. While the consumption of specific macronutrients like carbohydrates, proteins, and fats can affect weight management, the total calories consumed play the most significant role in determining body weight. Therefore, choices A, B, and C are incorrect as they focus on individual macronutrients rather than the overall energy balance provided by total kilocalories.

4. Which of the following terms describes the amount of blood ejected per heartbeat?

Correct answer: A

Rationale: The correct answer is A: Stroke volume. Stroke volume refers to the amount of blood ejected by the left ventricle in one contraction. Choice B, Cardiac output, is the total volume of blood pumped by the heart per minute and is calculated by multiplying stroke volume by heart rate. Choice C, Ejection fraction, is the percentage of blood pumped out of the left ventricle with each heartbeat. Choice D, Afterload, refers to the pressure or resistance that the ventricles must overcome to eject blood during systole. Therefore, in the context of the question, the term that specifically describes the amount of blood ejected per heartbeat is stroke volume.

5. Knowing that for a comatose patient hearing is the last sense to be lost, as Judy’s nurse, what should you do?

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

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