a nurse is planning care for a client who has a stage 3 pressure injury which of the following interventions should the nurse include in the plan a nurse is planning care for a client who has a stage 3 pressure injury which of the following interventions should the nurse include in the plan
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Nursing Elites

ATI RN

ATI RN Comprehensive Exit Exam

1. A client has a stage 3 pressure injury. Which of the following interventions should the nurse include in the plan?

Correct answer: D

Rationale: The correct intervention for a client with a stage 3 pressure injury is to apply a moisture barrier ointment. This helps protect the skin, maintain moisture balance, and promote healing. Choice A is incorrect because povidone-iodine solution can be too harsh for wound care. Choice B is incorrect as hydrogen peroxide can be cytotoxic to healing tissue. Choice C is important for preventing pressure injuries but is not a direct intervention for a stage 3 wound.

2. Causes of acute renal failure include:

Correct answer: D

Rationale: The correct answer is D. Severe injuries, like extensive burns, can cause acute renal failure due to shock, reduced blood flow to the kidneys, and tissue damage. Choices A, B, and C are incorrect because chronic renal failure, uncontrolled diabetes mellitus, and recurrent urinary tract infections are more likely to contribute to chronic kidney disease rather than acute renal failure.

3. When a client is taking Somatropin to stimulate growth, what should the healthcare provider monitor the client's urine for?

Correct answer: D

Rationale: When a client is taking Somatropin to stimulate growth, monitoring urine for calcium is essential. Somatropin can lead to increased calcium levels in the urine, potentially increasing the risk of renal calculi formation. Therefore, assessing for calcium in the urine helps in early detection and prevention of this complication. Monitoring for bilirubin, protein, or potassium in the urine is not directly related to the effects of Somatropin and would not provide relevant information in this context.

4. A nurse is caring for a client who is postoperative following surgical repair of a mandibular fracture with fixed occlusion of the jaws in a closed position. Which of the following statements is the priority for the nurse to make?

Correct answer: "Keep wire cutters with you at all times."

Rationale:

5. Which of the following birthmarks usually fade or regress as the child gets older?

Correct answer: D

Rationale: The correct answer is D. Hemangiomas, congenital dermal melanocytosis (i.e., Mongolian spots), and macular stains are birthmarks that usually fade or regress as the child gets older. Hemangiomas are vascular birthmarks that often shrink and fade over time. Congenital dermal melanocytosis (Mongolian spots) are blue-gray birthmarks commonly found on the lower back and buttocks of infants, which typically fade by adolescence. Macular stains, also known as salmon patches, are pink or red birthmarks that usually fade within the first few years of life. Choice D is correct because all the mentioned birthmarks tend to diminish as the child grows, unlike choices A, B, and C which do not fade or regress with age.

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