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 of c 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 of c
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Nursing Elites

ATI RN

ATI RN Exit Exam 2023

1. 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 of care?

Correct answer: D

Rationale: The correct answer is to use a moisture barrier ointment. This intervention helps protect the skin and promote healing in clients with stage 3 pressure injuries. Cleansing the wound with povidone-iodine solution daily (Choice A) can be too harsh and may delay healing by damaging the surrounding skin. Irrigating the wound with hydrogen peroxide (Choice B) is not recommended as it can be cytotoxic to healing tissue. While repositioning the client every 4 hours (Choice C) is an essential intervention in preventing pressure injuries, it is not directly related to the care of an existing stage 3 pressure injury.

2. A client with generalized anxiety disorder is prescribed buspirone (Buspar). Which statement by the client indicates a need for further teaching?

Correct answer: B

Rationale: The correct answer is B. Clients should not stop taking buspirone (Buspar) abruptly as it may cause withdrawal symptoms. Choice A is correct as buspirone can cause dizziness and drowsiness, so avoiding driving is important. Choice C is also accurate because buspirone may take several weeks to reach its full effectiveness. Choice D is valid as buspirone is not recommended during pregnancy due to potential risks to the fetus.

3. What should the nurse do first if they are stuck by a needle?

Correct answer: Flush the exposed skin with water

Rationale:

4. Which of the following nursing interventions is important for a client scheduled to have a Guaiac Test?

Correct answer: A

Rationale: The correct answer is A. Turnips, radish, and horseradish are known to cause false-positive results in a Guaiac Test, which is used to detect blood in the stool. Avoiding these foods is crucial to ensure accurate test results. Choice B is incorrect as iron preparation is not directly related to the Guaiac Test. Choice C is incorrect because avoiding meat is not specifically necessary before a Guaiac Test. Choice D is incorrect as caffeine and dark-colored foods can potentially interfere with test results, so they should not be encouraged.

5. Which type of fatty acid has carbon atoms connected by two or more double bonds?

Correct answer: D. Polyunsaturated fatty acids

Rationale: The correct answer is D. Polyunsaturated fatty acids. Polyunsaturated fatty acids have two or more double bonds in their carbon chains, making them less stable and more prone to oxidation. This characteristic distinguishes them from saturated fatty acids (Choice A), which have single bonds between carbon atoms providing stability. Monounsaturated fatty acids (Choice B) contain only one double bond, and trans fatty acids (Choice C) can have varying numbers of double bonds but are not specifically defined by having two or more double bonds.

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