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. A patient with chronic kidney disease has been prescribed a low-protein diet. What is the nurse's priority intervention?

Correct answer: D

Rationale: The correct answer is to monitor the patient's protein intake closely. In patients with chronic kidney disease on a low-protein diet, monitoring protein intake is crucial to prevent complications such as malnutrition or inadequate nutrient intake. Encouraging small, frequent meals (Choice A) can be beneficial but is not the priority over monitoring protein intake. Monitoring intake and output (Choice B) is important but does not directly address the specific focus on protein intake. Educating the patient on the benefits of a low-protein diet (Choice C) is essential but not as immediate as monitoring the actual protein intake.

3. Which action by the nurse will help reduce the risk of venous thromboembolism (VTE) in a postoperative patient?

Correct answer: A

Rationale: The correct answer is to encourage early ambulation and leg exercises. By promoting early ambulation and leg exercises, blood flow is enhanced, reducing the risk of venous thromboembolism (VTE) in postoperative patients. Choice B, applying compression stockings, helps prevent VTE but is not as effective as early ambulation and exercises. Choice C, administering anticoagulants, is important in VTE prevention but does not directly address improving circulation through physical activity. Choice D, elevating the patient's legs, may be beneficial for circulation in specific cases but is not as effective in preventing VTE as early ambulation and leg exercises.

4. What is the most important action for the nurse to take after finding a patient on the floor who reports, 'I fell out of bed'?

Correct answer: C

Rationale: The most important action for the nurse to take after finding a patient on the floor who reports falling out of bed is to notify the health care provider. This is crucial to ensure that the incident is reported, documented, and that the patient receives necessary follow-up care. Reassessing the patient is important, but notifying the healthcare provider takes precedence to address any potential injuries or issues that may have resulted from the fall. Completing an incident report is necessary, but immediate notification to the healthcare provider is more critical in this situation. Doing nothing is not an appropriate response, as the patient's safety and well-being must be the top priority.

5. A nurse is caring for a patient postoperatively after a thyroidectomy. Which of the following findings should be reported immediately?

Correct answer: D

Rationale: Tingling around the mouth should be reported immediately as it may indicate hypocalcemia, a serious complication resulting from accidental removal or damage to the parathyroid glands during thyroidectomy. Hoarseness and difficulty swallowing are common post-thyroidectomy symptoms related to the surgery itself and the manipulation of the vocal cords and nearby structures. Numbness in the fingers is not typically associated with immediate serious complications of a thyroidectomy.

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