a nurse is caring for a client who has diaper dermatitis which of the following actions should the nurse take
Logo

Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023

1. A nurse is caring for a client who has diaper dermatitis. Which of the following actions should the nurse take?

Correct answer: A

Rationale: Correct answer: Applying zinc oxide ointment to the irritated area is the most appropriate action for diaper dermatitis. Zinc oxide is a barrier cream that helps protect the skin and promote healing. Choice B is incorrect because using store-bought baby wipes may contain chemicals or fragrances that can further irritate the skin. Choice C is incorrect as talcum powder can also worsen the condition by drying out the skin. Choice D is incorrect because a warm compress is not typically used for diaper dermatitis; it may provide relief for other conditions but is not the best option for diaper dermatitis.

2. A nurse is developing a care plan for a client who has paraplegia and has an area of nonblanchable erythema over the ischium. Which intervention should the nurse include?

Correct answer: B

Rationale: The correct intervention for a client with nonblanchable erythema over the ischium is to teach the client to shift his weight every 15 minutes while sitting. This action helps relieve pressure on the affected area and prevents further skin breakdown. Placing the client upright on a donut-shaped cushion (Choice A) may not address the need for frequent weight shifts. Turning and repositioning the client every 3 hours (Choice C) is important for overall skin health but may not provide adequate relief for the specific area of nonblanchable erythema. Assessing pressure points every 24 hours (Choice D) is not frequent enough to prevent worsening of the skin condition in this case.

3. A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following findings should the nurse report to the provider?

Correct answer: D

Rationale: The correct answer is D. A weight gain of 1.5 kg (3.3 lb) in 24 hours can indicate fluid retention and worsening heart failure in clients taking digoxin. This rapid weight gain could be due to fluid accumulation, a common sign of heart failure exacerbation. Reporting this finding to the provider is crucial for prompt intervention. Choices A, B, and C are within normal ranges and not directly indicative of worsening heart failure in this context, making them less urgent to report compared to the significant weight gain.

4. A nurse is assessing a client who is receiving morphine for pain management. Which of the following findings should the nurse report to the provider?

Correct answer: C

Rationale: The correct answer is C. A respiratory rate of 10/min indicates respiratory depression, a serious adverse effect of morphine that should be reported immediately. Options A, B, and D are within normal limits and are not indicative of a potentially life-threatening complication associated with morphine therapy.

5. A nurse is providing discharge instructions to a client who has tuberculosis and a new prescription for rifampin. Which of the following statements by the client indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B. Rifampin can cause a harmless reddish-orange discoloration of body fluids, including urine. Choice A is not related to rifampin; vision changes are not a common side effect of the medication. Choice C is more relevant to medications that cause photosensitivity reactions, not specifically rifampin. Choice D is incorrect because nausea is a common side effect of rifampin, but it does not warrant immediate discontinuation of the medication.

Similar Questions

When preparing education materials for a client, what technique should be used to make the information accessible?
How should a healthcare provider manage a patient with chronic kidney disease?
A client has a new prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include?
A nurse is caring for a client who has chronic kidney disease and a serum potassium level of 6.5 mEq/L. Which of the following actions should the nurse take?
When discussing clients designating a health care proxy in situations requiring a durable power of attorney for health care (DPAHC), what information should the charge nurse include?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses