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

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?

A. Cleanse the wound with povidone-iodine solution daily.
B. Irrigate the wound with hydrogen peroxide.
C. Reposition the client every 4 hours.
D. Use a moisture barrier ointment.

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

A. Explain the risks of the surgery in detail.
B. Tell the client that many clients feel anxious before surgery.
C. Reassure the client that the surgical team is highly experienced.
D. Acknowledge the client's feelings and ask open-ended questions.

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.

3. A nurse is planning care for a client who is experiencing acute mania. What intervention should the nurse include?

A. Encourage the client to take frequent rest periods.
B. Withdraw TV privileges if the client does not attend group therapy.
C. Place the client in seclusion during periods of anxiety.
D. Encourage the client to spend time in the day room.

Correct answer: A

Rationale: The correct answer is A: Encourage the client to take frequent rest periods. During acute mania, individuals often experience high levels of energy, decreased need for sleep, and increased activity levels. Encouraging the client to take frequent rest periods can help prevent exhaustion and promote better self-regulation. Choice B is incorrect because withdrawing TV privileges may not be directly related to managing acute mania. Choice C is incorrect as placing the client in seclusion can exacerbate feelings of anxiety and agitation. Choice D is incorrect as spending time in the day room may not address the need for rest and relaxation that is crucial during acute mania.

4. How should a healthcare professional administer a subcutaneous injection?

A. Insert the needle at a 45-degree angle
B. Insert the needle at a 90-degree angle
C. Use a Z-track method
D. Insert the needle at a 15-degree angle

Correct answer: A

Rationale: The correct technique for administering subcutaneous injections is to insert the needle at a 45-degree angle. This angle ensures that the medication is delivered into the subcutaneous tissue, which is located just below the skin. Inserting the needle at a 90-degree angle is more appropriate for intramuscular injections, while using a Z-track method is specific to intramuscular injections to prevent leakage of medication into the subcutaneous tissue. Inserting the needle at a 15-degree angle would not reach the subcutaneous tissue effectively.

5. A client with bipolar disorder and experiencing mania is under the care of a nurse. Which intervention should the nurse include in the plan?

A. Encourage the client to spend time in the day room.
B. Withdraw the client's TV privileges if they do not attend group therapy.
C. Encourage the client to take frequent rest periods.
D. Place the client in seclusion when they exhibit signs of anxiety.

Correct answer: C

Rationale: Encouraging the client to take frequent rest periods is the appropriate intervention when caring for a client with bipolar disorder experiencing mania. During manic episodes, individuals often exhibit hyperactivity and may become exhausted. Rest periods can help reduce these symptoms. Choices A, B, and D are incorrect. Spending time in the day room may not address the client's need for rest, withdrawing TV privileges is not directly related to managing mania symptoms, and placing the client in seclusion when anxious can escalate the situation rather than promoting a calming environment.