a nurse is assessing a client who is at risk for pressure injuries which intervention should the nurse include in the plan of care
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Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. A nurse is assessing a client who is at risk for pressure injuries. Which intervention should the nurse include in the plan of care?

Correct answer: B

Rationale: The correct answer is B: 'Use a special mattress for the client.' Using a special mattress reduces pressure on bony prominences and helps prevent pressure injuries. Repositioning the client every 4 hours (choice A) is important but using a special mattress is more effective. Keeping the client on bedrest (choice C) can increase the risk of pressure injuries due to prolonged immobility. Encouraging the client to remain in one position (choice D) is incorrect as it can lead to pressure injuries by exerting pressure on the same areas for an extended period.

2. A nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. Which food should the nurse instruct the client to avoid?

Correct answer: B

Rationale: Correct! Orange slices should be avoided by clients on a mechanical soft diet as they can be difficult to chew and swallow. Steamed carrots, mashed potatoes, and baked chicken are suitable choices for a mechanical soft diet, as they are softer in texture and easier to consume without posing a risk of choking or swallowing difficulties.

3. A nurse is providing discharge teaching to a client with a prescription for home oxygen therapy. What information should the nurse include?

Correct answer: C

Rationale: The correct answer is C: 'Avoid open flames or smoking near oxygen.' This information is crucial to prevent fire hazards as oxygen supports combustion. Choices A, B, and D are incorrect. Increasing the oxygen flow rate without healthcare provider's instructions can be dangerous. Oxygen should not be turned off when not in use as prescribed by the healthcare provider, and storing oxygen tubing near heat sources poses a risk of fire.

4. A nurse is planning to administer several medications to a client through a nasogastric (NG) tube. What action should the nurse take?

Correct answer: D

Rationale: The correct action for the nurse to take when administering medications through a nasogastric (NG) tube is to dissolve medications separately and flush the tube with sterile water. This is important to prevent interactions between medications and ensure accurate administration. Option A is incorrect because tap water may not be sterile and could lead to contamination. Option B is incorrect as it increases the risk of drug interactions and may affect the effectiveness of each medication. Option C is incorrect as 60 mL of water before each medication may not be enough to ensure proper medication delivery and prevent interactions.

5. A client with diabetes mellitus is being taught about foot care by a nurse. What statement indicates understanding?

Correct answer: B

Rationale: The correct answer is B. Wearing cotton socks is essential for clients with diabetes as it helps protect the feet and reduces the risk of skin breakdown. Choice A is incorrect because soaking feet in hot water can lead to burns or skin damage. Choice C is incorrect as clients with diabetes should cut their toenails straight across to prevent ingrown toenails. Choice D is incorrect as applying lotion between the toes can create a moist environment that may increase the risk of fungal infections.

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