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 providing discharge teaching to a client who has a wound infection. Which of the following information should the nurse include about home care?

Correct answer: D

Rationale: The correct answer is D: 'Keep the wound covered with a dry dressing.' When providing care for a wound infection, it is essential to keep the wound covered with a dry dressing to prevent further contamination and promote healing. Soaking the wound in warm water (choice A) can introduce moisture and increase the risk of infection. Using hydrogen peroxide (choice B) can be too harsh and may slow down the healing process by damaging healthy tissue. Applying a cold compress (choice C) is not typically recommended for wound infections, as it may not provide the necessary environment for healing.

3. A client with a new diagnosis of type 1 diabetes mellitus is being taught by a nurse. Which of the following client statements indicates an understanding of the teaching?

Correct answer: C

Rationale: The correct answer is C. Clients with type 1 diabetes should rotate injection sites within the same anatomical region to prevent lipodystrophy. Choice A is incorrect because blood glucose levels should be checked regularly, not only when feeling sick. Choice B is incorrect as injecting insulin in the same spot each time can lead to lipodystrophy. Choice D is incorrect as insulin injections are usually required based on meal schedules and blood glucose levels, not just when levels are above 200 mg/dL.

4. A nurse is reviewing the facility's safety protocols concerning newborn abduction with the parent of a newborn. Which of the following statements indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B. Not making public announcements about the baby's birth is crucial in preventing newborn abduction as it avoids exposing personal information. Choice A is incorrect because the identification band should be applied immediately after birth, not after the first bath. Choice C is incorrect as the baby's identification band should never be removed by the parent. Choice D is incorrect as parents should not leave their baby unattended in the room while they are outside the room.

5. A client expresses fear of surgery. Which response should the nurse make?

Correct answer: D

Rationale: When a client expresses fear of surgery, it is essential for the nurse to acknowledge their feelings and ask open-ended questions. This response shows empathy, validates the client's emotions, and encourages them to express their concerns further. Explaining the risks of the surgery in detail (Choice A) may increase the client's anxiety. Simply stating that many clients feel anxious before surgery (Choice B) does not address the client's specific fears. While reassuring the client about the surgical team's experience (Choice C) is important, it may not directly alleviate the client's fear.

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