a nurse is caring for an older adult who has a nonpalpable skin lesion that is less than 05cm 02in in diameter which term should the nurse use to docu
Logo

Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. A nurse is caring for an older adult who has a nonpalpable skin lesion that is less than 0.5cm (0.2in) in diameter. Which term should the nurse use to document this finding?

Correct answer: B

Rationale: The correct answer is B: Macule. A macule is a flat, nonpalpable skin lesion that is smaller than 1 cm in diameter. In this case, the lesion is less than 0.5cm, fitting the description of a macule. A papule (choice A) is a solid, elevated lesion less than 0.5 cm in diameter. A nodule (choice C) is a solid, elevated lesion that is 0.5 cm or larger in diameter. A tumor (choice D) refers to a mass of abnormal tissue growth, which is not applicable in this scenario.

2. A client has a new prescription for a metered-dose inhaler (MDI). What instruction should the nurse include?

Correct answer: C

Rationale: The correct instruction for a client using a metered-dose inhaler (MDI) is to hold the inhaler 1-2 inches from the mouth. This distance allows for the proper delivery of the medication into the lungs. Choice A is incorrect because the duration of inhalation can vary depending on the medication, and 1 second may not be adequate. Choice B is incorrect as shaking the inhaler vigorously is not necessary for all MDIs and can lead to inaccurate dosing. Choice D is incorrect as the client should hold their breath for about 10 seconds after inhalation to allow the medication to deposit in the lungs.

3. A nurse is providing discharge instructions to a client who has been prescribed a mechanical soft diet. What food should the nurse instruct the client to avoid?

Correct answer: B

Rationale: The correct answer is B: Orange slices. For a client on a mechanical soft diet, foods that are difficult to chew and swallow should be avoided. Orange slices fall into this category due to their texture and potential choking hazard. Steamed carrots, mashed potatoes, and baked chicken are typically suitable for a mechanical soft diet as they can be easily mashed or cut into small, manageable pieces for consumption.

4. A nurse is planning a community education program about colorectal cancer. What risk factors should the nurse identify as modifiable?

Correct answer: B

Rationale: The correct answer is B: High-fat diet, smoking, alcohol consumption. These are modifiable risk factors for colorectal cancer as individuals can make lifestyle changes to reduce their risk. Age and gender (choice A) are non-modifiable risk factors. Ethnicity and race (choice C) can influence the risk of colorectal cancer but are not modifiable factors. Exposure to radiation (choice D) is not a common modifiable risk factor for colorectal cancer.

5. A client at risk for pressure injuries is being cared for by a nurse. What intervention should the nurse implement?

Correct answer: B

Rationale: The correct intervention for a client at risk for pressure injuries is to use a special mattress. Special mattresses help reduce the risk of pressure injuries by redistributing pressure on bony areas, thus preventing tissue damage. Keeping the client in one position (choice A) can actually increase the risk of pressure injuries due to prolonged pressure on specific areas. Turning the client every 4 hours (choice C) is important for preventing pressure injuries, but using a special mattress is a more effective intervention. Providing extra pillows for positioning (choice D) may offer some comfort but does not address the primary intervention of pressure redistribution that a special mattress provides.

Similar Questions

A nurse is teaching about food choices for a client on a low-sodium diet. What food should the nurse recommend?
A nurse is caring for a client who is postoperative following cataract surgery. The client reports that they do not want to wear their eye shield. What should the nurse do?
A nurse is assessing a client who reports pain and redness at the site of a peripheral IV. What should the nurse do first?
A nurse is providing discharge teaching for a client with chronic obstructive pulmonary disease (COPD). What instruction should the nurse include to help improve oxygenation?
While documenting client care, which entry should the nurse identify as an example of implementing client care?

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