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 nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse include?

Correct answer: A

Rationale: The correct action for the nurse to include in the plan of care for an older adult at risk for falls is to lock beds and wheelchairs when not in use. This measure is crucial for preventing falls and ensuring patient safety in healthcare settings. Administering sedatives at bedtime (Choice B) is not recommended as it does not address the underlying risk factors for falls and may increase the risk of injury. Providing information about home safety checks (Choice C) is important for fall prevention in the home environment but is not directly related to healthcare settings. Teaching balance and strengthening exercises (Choice D) is beneficial for fall prevention but may not be suitable for all older adults at risk for falls, especially in acute care settings.

3. A client has a new prescription for lisinopril. Which of the following statements indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B. Reporting a cough is crucial when taking lisinopril as it can be a sign of a serious side effect, such as angioedema or cough associated with ACE inhibitors. Option A is incorrect because lisinopril can be taken with or without food. Option C is incorrect as facial swelling is not an expected side effect of lisinopril. Option D is incorrect because lisinopril can cause hyperkalemia, so increasing potassium-rich foods without healthcare provider guidance can be dangerous.

4. A client has a new prescription for beclomethasone inhaler to use with an albuterol inhaler for asthma maintenance. What should the nurse instruct the client?

Correct answer: C

Rationale: The correct answer is to instruct the client to gargle with water after each use of the beclomethasone inhaler. Beclomethasone can cause oral thrush, and gargling with water helps prevent this complication. Choice A is incorrect because the client should not skip doses even if breathing improves, as the medications are prescribed for maintenance. Choice B is incorrect as there is no specific instruction to use the albuterol inhaler first in this scenario. Choice D is incorrect because inhalers should not be stored in the refrigerator unless specified by the manufacturer.

5. A client with tuberculosis is about to start combination drug therapy. Which of the following medications should the nurse plan to administer? (SATA)

Correct answer: B

Rationale: The correct answer is B: Pyrazinamide. In the treatment of tuberculosis, a combination drug therapy is usually employed. Pyrazinamide and rifampin are two key drugs used in this regimen. Acyclovir is an antiviral medication used for herpes infections, not for tuberculosis. Isoniazid is another medication used in tuberculosis treatment, but in this case, the question asked for medications to administer, and the correct choices should be those commonly used in tuberculosis combination therapy.

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