a nurse is planning care for a client who has alzheimers disease and demonstrates confusion and wandering behavior which of the following should the n
Logo

Nursing Elites

ATI RN

ATI RN Comprehensive Exit Exam 2023

1. A nurse is planning care for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care?

Correct answer: C

Rationale: The correct answer is to dim the lighting in the client's room. Dim lighting can help reduce confusion and agitation in clients with Alzheimer's disease. Placing the client in seclusion (Choice A) is not recommended as it can lead to feelings of isolation and distress. Requesting PRN restraints (Choice B) should be avoided in clients with Alzheimer's as it can increase agitation and pose safety risks. Leaving one side rail up on the client's bed (Choice D) may not directly address the client's confusion and wandering behavior.

2. A nurse is planning care for a client who has a stage 2 pressure injury. Which of the following interventions should the nurse include in the plan?

Correct answer: D

Rationale: The correct answer is to apply a hydrocolloid dressing. For a stage 2 pressure injury, maintaining a moist environment is crucial for healing. Hydrocolloid dressings help achieve this by promoting autolytic debridement and creating a barrier against bacteria while allowing the wound to heal. Applying a dry dressing (Choice A) may not provide the necessary moisture for healing. Cleansing the wound with normal saline (Choice B) is essential, but a hydrocolloid dressing is more specific for promoting healing in this case. Performing debridement as needed (Choice C) is not typically indicated for stage 2 pressure injuries, as they involve partial-thickness skin loss without slough or eschar.

3. How should a healthcare provider care for a patient with a tracheostomy?

Correct answer: C

Rationale: Suctioning the tracheostomy regularly is crucial in caring for a patient with a tracheostomy as it helps keep the airway clear of secretions, preventing blockages and potential complications. Cleaning the tracheostomy site daily is important for hygiene but not as critical as regular suctioning. Changing the tracheostomy ties daily may not be necessary unless soiled or loose. Providing humidified oxygen may be part of the care plan but is not as directly related to maintaining the tracheostomy patency as suctioning.

4. Which lab value should be monitored in patients receiving furosemide?

Correct answer: A

Rationale: The correct answer is to monitor potassium levels in patients receiving furosemide. Furosemide is a loop diuretic that can lead to potassium loss in the urine, potentially causing hypokalemia. Monitoring potassium levels is crucial to prevent complications associated with low potassium levels, such as cardiac arrhythmias. Monitoring sodium levels (choice B) is not typically necessary with furosemide use, as it primarily affects potassium levels. Calcium levels (choice C) and glucose levels (choice D) are not directly impacted by furosemide and require monitoring for other conditions or medications.

5. A nurse is caring for a client who is postoperative following a hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation of the prosthesis?

Correct answer: A

Rationale: Placing a pillow between the client's legs is the correct action to prevent dislocation of the prosthesis after hip arthroplasty. This positioning helps maintain proper alignment and stability of the hip joint, reducing the risk of dislocation. Placing the client in a high Fowler's position (choice B) is not recommended after hip arthroplasty as it may strain the hip joint. Maintaining the client in a side-lying position (choice C) or keeping the client's legs elevated (choice D) does not provide the same level of support and alignment as placing a pillow between the legs.

Similar Questions

A healthcare provider is preparing to administer an intramuscular injection to a client. Which of the following actions should the provider take?
A healthcare provider is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which finding should the healthcare provider identify as a contraindication to the administration of clozapine?
What is the most critical lab value to monitor for a patient on heparin therapy?
A nurse is caring for a client who has pneumonia. Which of the following findings should the nurse identify as an indication of the effectiveness of the treatment?
A nurse is providing discharge teaching to a client who has a new prescription for albuterol. Which of the following instructions 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