how can a nurse prevent pressure ulcers in an immobile patient
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN

1. How can a healthcare provider prevent pressure ulcers in an immobile patient?

Correct answer: B

Rationale: Providing the immobile patient with a special mattress is an effective way to prevent pressure ulcers. Special mattresses help distribute pressure evenly and reduce the risk of developing pressure ulcers by relieving pressure on sensitive areas. Turning the patient every 4 hours (Choice A) is a standard practice to prevent pressure ulcers but may not be as effective as using a special mattress. Elevating the patient's legs (Choice C) can help with circulation but may not directly prevent pressure ulcers. Limiting the patient's movement (Choice D) can lead to other complications and is not a recommended method for preventing pressure ulcers.

2. When considering a bone marrow transplant for a client with leukemia, which ethical principle pertains to minimizing harm to the client?

Correct answer: B

Rationale: The correct answer is B: Nonmaleficence. Nonmaleficence is the ethical principle that emphasizes the obligation to do no harm, making it crucial in medical decision-making. In the context of a bone marrow transplant for a client with leukemia, the primary concern is to minimize harm and avoid causing any unnecessary suffering or adverse effects. Choices A, C, and D are incorrect: Justice relates to fairness in resource allocation and treatment decisions, Autonomy involves respecting the patient's right to make decisions about their own care, and Beneficence refers to the obligation to act in the patient's best interest and promote their well-being, which may involve some level of risk or harm for overall benefit.

3. What is the priority action when a patient is experiencing an allergic reaction to a medication?

Correct answer: B

Rationale: The correct answer is to discontinue the medication and notify the healthcare provider when a patient is experiencing an allergic reaction to a medication. This action is crucial to prevent further harm to the patient. Monitoring blood pressure (choice A) or urine output (choice D) may be important but is not the priority when managing an allergic reaction. Administering an antihistamine (choice C) should only be done after discontinuing the medication and consulting with the healthcare provider.

4. A nurse is assessing a client who has heart failure and is taking digoxin. The nurse should monitor the client for which of the following manifestations as an indication of digoxin toxicity to report to the provider?

Correct answer: B

Rationale: The correct answer is B: Vomiting. Vomiting is a common sign of digoxin toxicity and should be reported to the healthcare provider. Diarrhea (Choice A) is a more common side effect of digoxin but not typically associated with toxicity. Ringing in the ears (Choice C) is a potential sign of toxicity; however, vomiting is a more immediate concern. Dizziness (Choice D) can occur with digoxin use but is not a specific indicator of toxicity.

5. A nurse is preparing to administer a blood transfusion. What is the most important action to ensure patient safety?

Correct answer: B

Rationale: The most important action to ensure patient safety when administering a blood transfusion is to verify the patient's identity with two identifiers before starting the transfusion. This step is crucial to prevent transfusion errors, such as giving the blood to the wrong patient. Checking vital signs, ensuring timely administration, and confirming informed consent are also important aspects of blood transfusion safety but verifying the patient's identity is the highest priority to prevent errors.

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