a nurse is reviewing the health history of a client who has a hip fracture what risk factor should the nurse identify for developing pressure injuries
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Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. A nurse is reviewing the health history of a client who has a hip fracture. What risk factor should the nurse identify for developing pressure injuries?

Correct answer: B

Rationale: Corrected Rationale: Poor nutrition increases the risk of developing pressure injuries as it impairs skin integrity and healing. Frequent repositioning, increased fluid intake, and the use of a special mattress are all important interventions for preventing pressure injuries, rather than risk factors for developing them. Repositioning helps relieve pressure, adequate fluid intake maintains skin hydration, and special mattresses redistribute pressure to prevent injuries.

2. A client who is at risk for developing a deep vein thrombosis (DVT) after surgery. What intervention should the nurse implement to reduce this risk?

Correct answer: B

Rationale: The correct intervention to reduce the risk of deep vein thrombosis (DVT) after surgery is to use compression stockings. Compression stockings help prevent DVT by promoting venous return, which reduces the likelihood of blood pooling in the legs and forming clots. Choices A, C, and D are incorrect because avoiding ambulation can actually increase the risk of DVT, using a heating pad does not directly address DVT prevention, and elevating the client's legs on a pillow alone may not provide sufficient compression to prevent DVT.

3. A nurse is caring for a client who has a prescription for a narcotic medication. What should the nurse do with the unused portion after administration?

Correct answer: B

Rationale: The correct action for the nurse to take with the unused portion of a narcotic medication after administration is to discard it with a witness present. This procedure is necessary to comply with controlled substance regulations and prevent diversion or misuse of the medication. Storing it in the medication cart for later use is inappropriate as it can lead to unauthorized access. Returning it to the pharmacy is not recommended as the medication has already been dispensed. Reporting it to the provider is not the standard procedure for disposing of controlled substances.

4. A nurse is providing discharge instructions to a client with a prescription for home oxygen therapy. What information should the nurse include?

Correct answer: C

Rationale: The correct answer is C: 'Avoid open flames or smoking near oxygen.' This information is crucial to prevent fires because oxygen supports combustion. Choices A, B, and D are incorrect. Choice A is not relevant to oxygen therapy. Choice B is incorrect as oxygen should not be turned off when in use as prescribed. Choice D is incorrect because adjusting the oxygen flow rate without healthcare provider guidance can be dangerous.

5. A nurse is providing discharge teaching to a client with a new diagnosis of hypertension. What instruction should the nurse include?

Correct answer: C

Rationale: The correct answer is C: 'Take prescribed antihypertensive medications daily.' When providing discharge teaching to a client with hypertension, one of the key instructions is to ensure the consistent intake of prescribed antihypertensive medications. This is crucial for controlling blood pressure levels and reducing the risk of complications associated with hypertension. Choices A, B, and D are incorrect because reducing sodium intake, avoiding foods high in potassium, and limiting fluid intake are important dietary modifications for various health conditions, but they are not the priority when it comes to managing hypertension. The primary focus should be on medication adherence to effectively manage hypertension.

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