what is the priority nursing intervention for a patient with a stage 3 pressure ulcer
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Nursing Elites

ATI RN

ATI RN Exit Exam 2023

1. What is the priority nursing intervention for a patient with a stage 3 pressure ulcer?

Correct answer: A

Rationale: The correct answer is to apply a hydrocolloid dressing. Stage 3 pressure ulcers are characterized by full-thickness skin loss involving damage to or necrosis of subcutaneous tissue, which requires a moist environment for healing. Hydrocolloid dressings help maintain a moist wound environment, promote healing, and provide protection. Providing wound debridement may be necessary but is not the priority intervention at this stage. Changing the dressing daily is important for wound care but not the priority over creating an optimal healing environment. Elevating the affected area can help with circulation and reduce swelling, but it is not the priority intervention for a stage 3 pressure ulcer.

2. A nurse is administering medications to a group of clients. Which of the following occurrences requires the completion of an incident report?

Correct answer: A

Rationale: The correct answer is A. When a client receives antibiotics 2 hours late, it constitutes a medication error, requiring the completion of an incident report. Choice B, a client vomiting within 20 minutes of taking medications, does not necessarily require an incident report unless it is suspected to be related to a medication error. Choice C, a client requesting a statin at a specific time, and choice D, a client asking for pain medication an hour early, are not incidents that mandate the completion of an incident report unless there are specific circumstances indicating otherwise.

3. How should fluid balance be assessed in a patient with heart failure?

Correct answer: A

Rationale: In patients with heart failure, monitoring daily weight is the most accurate method for assessing fluid balance. Weight gain can indicate fluid retention, a common issue in heart failure patients. Monitoring input and output (B) is essential but may not always accurately reflect fluid balance. Checking for edema (C) is important as it can indicate fluid accumulation, but daily weight monitoring is more precise. Monitoring blood pressure (D) is important in heart failure management but does not directly assess fluid balance.

4. How should a healthcare professional monitor a patient on furosemide for fluid balance?

Correct answer: A

Rationale: Monitoring a patient's daily weight is crucial when assessing fluid balance in individuals prescribed furosemide. Furosemide is a diuretic that helps the body eliminate excess fluid and salt. Changes in weight can reflect fluid shifts, making daily weight monitoring a reliable indicator of fluid status. While checking for edema and monitoring input and output are essential aspects of fluid balance assessment, they may not provide as immediate and quantifiable information as daily weight measurements. Monitoring blood pressure is important in patients on furosemide due to its potential to affect blood pressure levels, but it is not as directly indicative of fluid balance as daily weight monitoring.

5. Which electrolyte imbalance is commonly seen in patients receiving furosemide?

Correct answer: A

Rationale: The correct answer is A: Hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss, resulting in hypokalemia. This electrolyte imbalance necessitates close monitoring to prevent complications such as cardiac arrhythmias. Choices B, C, and D are incorrect. Hypercalcemia is not a common side effect of furosemide. Hyponatremia is more commonly associated with other medications like thiazide diuretics. Hyperkalemia is the opposite electrolyte imbalance and is not typically seen with furosemide use.

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