how should a nurse position a patient to reduce the risk of pressure ulcers
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN

1. How should a healthcare professional position a patient to reduce the risk of pressure ulcers?

Correct answer: B

Rationale: Correctly positioning a patient to reduce the risk of pressure ulcers involves using pillows to support bony prominences. This helps to relieve pressure from vulnerable areas and prevent the development of pressure ulcers. Choice A is incorrect because keeping a patient in the supine position for extended periods can increase the risk of pressure ulcers. Choice C is incorrect as turning the patient every 2 hours, rather than every 4 hours, is recommended to prevent pressure ulcers. Choice D is not the best option mentioned for positioning a patient to reduce pressure ulcer risk; although alternating pressure mattresses can be beneficial, using pillows for support is a more direct and commonly used method.

2. The healthcare provider is assessing an immobile patient for deep vein thrombosis (DVT). What should the healthcare provider do?

Correct answer: C

Rationale: Measuring the calf circumference of both legs is crucial when assessing for DVT in an immobile patient. A significant increase in the circumference of one calf compared to the other suggests the presence of a deep vein thrombosis. Option A is incorrect because rubbing the lower leg may dislodge a clot if present. Option B is incorrect as elastic stockings should not be removed frequently as this can increase the risk of clot formation. Option D is incorrect as dorsiflexing the foot can lead to pain and should not be done to assess for DVT.

3. The nurse is caring for a patient on contact precautions. Which action will be most appropriate to prevent the spread of disease?

Correct answer: D

Rationale: The correct answer is to use a dedicated blood pressure cuff that stays in the room and is used for that patient only. Patients on contact precautions require dedicated equipment to prevent the spread of disease. Using one blood pressure cuff exclusively for the patient on contact precautions helps minimize the risk of transmitting infections to other patients. Choices A, B, and C are incorrect because while wearing protective gear and isolating the patient in a room with negative airflow are important infection control measures, using dedicated equipment for the patient on contact precautions is specifically recommended to prevent the spread of disease in this scenario.

4. A patient has difficulty ambulating after surgery. Which action should the nurse take first?

Correct answer: C

Rationale: The correct first action for the nurse to take when a patient has difficulty ambulating after surgery is to call for assistance with ambulation. This is essential to ensure the safety of the patient and prevent any potential falls or injuries. Encouraging deep breathing exercises (Choice A) may be beneficial but should not be the first priority when the patient is having difficulty walking. Assisting the patient in ambulating a short distance (Choice B) may put both the patient and the nurse at risk if the patient is struggling. Assessing the patient's pain level before ambulation (Choice D) is important but should come after ensuring that the patient can safely ambulate with assistance.

5. A patient with a left arm fracture reports severe pain unrelieved by medication. What should the nurse assess for?

Correct answer: A

Rationale: Correct answer: When a patient with a left arm fracture reports severe pain unrelieved by medication, the nurse should assess for compartment syndrome. Compartment syndrome is a condition where increased pressure within a muscle compartment compromises circulation and can lead to tissue damage. It is a surgical emergency that requires immediate intervention. Choice B is incorrect because simply increasing pain medication without identifying the cause of the unrelieved pain may mask symptoms of a serious issue like compartment syndrome. Choice C is incorrect as surgery would only be necessary if compartment syndrome is confirmed. Choice D is incorrect as administering a sedative does not address the underlying issue of unrelieved pain and may delay appropriate treatment.

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