a nurse is caring for a client who is at risk for developing pressure ulcers which of the following interventions should the nurse implement
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Nursing Elites

ATI RN

ATI Exit Exam 2024

1. A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse implement?

Correct answer: C

Rationale: Elevating the head of the bed reduces pressure on bony prominences, which helps prevent pressure ulcers.

2. A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions about the disease. To research, the nurse should identify which of the following electronic databases has the most comprehensive collection of nursing articles?

Correct answer: B

Rationale: The correct answer is B, CINAHL. CINAHL is specifically dedicated to nursing and allied health literature, making it the most appropriate database for nursing articles and research. It provides a comprehensive collection of nursing-related articles, journals, and research studies, which are essential for evidence-based practice. MEDLINE, on the other hand, is a valuable resource for medical literature but is not as nursing-focused as CINAHL. ProQuest and Health Source cover a wider range of subjects beyond nursing, so they are not as comprehensive when it comes to nursing-specific articles and research. Therefore, for the nurse looking to access a database with a vast collection of nursing articles, CINAHL is the most suitable option.

3. A nurse is reviewing the plan of care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse expect to include?

Correct answer: C

Rationale: Providing high-calorie snacks is essential when caring for a client in the manic phase of bipolar disorder because they often have increased energy expenditure and may not eat adequately due to their heightened activity levels. Encouraging group activities (Choice A) may overwhelm the client further during this phase. Encouraging frequent naps (Choice B) contradicts the need to manage increased energy levels. Promoting physical activity during mealtimes (Choice D) may not be appropriate as it can distract the client from eating, which is crucial in meeting their nutritional needs.

4. A nurse is planning care for a client who has a stage 2 pressure injury. Which of the following interventions should the nurse include?

Correct answer: B

Rationale: The correct answer is B: Apply a hydrocolloid dressing. Applying a hydrocolloid dressing helps create a moist environment that promotes healing in clients with stage 2 pressure injuries. Choice A, cleansing the wound with povidone-iodine, is not recommended for stage 2 pressure injuries as it can be too harsh on the skin. Performing debridement as needed, as mentioned in choice C, is not typically indicated for stage 2 pressure injuries, which involve partial-thickness skin loss. Keeping the wound open to air, as stated in choice D, is also not the preferred approach for managing stage 2 pressure injuries, as maintaining a moist environment is key to promoting healing.

5. A nurse is providing discharge teaching to a client who has a new prescription for metformin. Which of the following instructions should the nurse include?

Correct answer: D

Rationale: The correct answer is D because taking metformin with food helps reduce gastrointestinal discomfort, a common side effect of the medication. Choice A is incorrect as metformin is usually taken with meals to minimize side effects. Choice B is incorrect because metformin does not typically cause urine discoloration. Choice C is incorrect as metformin is associated with weight loss or weight neutrality rather than weight gain.

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