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
Logo

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. What is the best method to assess pain in a non-verbal patient?

Correct answer: A

Rationale: The correct answer is to observe for facial expressions when assessing pain in a non-verbal patient. Facial expressions can provide vital clues about the patient's pain level and discomfort. Choices B and C, observing for restlessness and sweating, can be less specific and may indicate other issues besides pain. Choice D, checking for non-verbal cues, is too broad and does not specify the crucial aspect of focusing on facial expressions.

3. What is the most important nursing assessment post-surgery?

Correct answer: A

Rationale: The correct answer is to monitor vital signs post-surgery. Vital signs encompass various parameters like blood pressure, heart rate, respiratory rate, and temperature. Monitoring vital signs helps in early detection of complications such as hemorrhage, infection, or shock. While monitoring the surgical site and incision site are also essential post-surgery, monitoring vital signs takes precedence as it provides a broader assessment of the patient's overall condition. Monitoring blood pressure is part of vital sign assessment and is not the most comprehensive assessment post-surgery.

4. A nurse is providing teaching about newborn care to a group of parents. Which of the following instructions should the nurse include?

Correct answer: D

Rationale: The correct answer is D: 'You should keep your newborn's head elevated while they sleep.' Keeping the newborn's head elevated while sleeping helps prevent conditions like sudden infant death syndrome (SIDS). Choice A is incorrect because newborns do not need to be bathed every day; it is recommended to bathe them 2-3 times a week. Choice B is incorrect as heavy blankets can increase the risk of suffocation for newborns. Choice C is incorrect as newborn stools are typically soft and yellow in color, not firm and light brown.

5. A healthcare professional is providing discharge teaching for a client with type 2 diabetes mellitus. Which resource should be provided?

Correct answer: D

Rationale: Food exchange lists from the American Diabetes Association are a valuable resource for meal planning in diabetes. These lists provide guidelines for portion control and help individuals make healthier food choices. Personal blogs may not always provide accurate and evidence-based information. Food label recommendations are important but may not specifically address meal planning for diabetes. Diabetes medication information is essential but not the primary focus when educating about dietary management for type 2 diabetes.

Similar Questions

A nurse is providing teaching to a client who has a new prescription for nitroglycerin transdermal patches. Which of the following instructions should the nurse include?
A parent is being taught by a nurse how to prevent sudden infant death syndrome (SIDS). Which statement by the parent indicates an understanding of how to place the infant in the crib at bedtime?
A nurse is caring for a client who has deep vein thrombosis of the left lower extremity. Which of the following actions should the nurse take?
A nurse is caring for a client who is receiving radiation therapy. Which of the following findings should the nurse expect?
A nurse is developing a care plan for a client who is receiving nitroprusside for severe hypertension. Which action should the 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