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 nurse is caring for a client who has a prescription for a narcotic medication. After administration, what should the nurse do with the unused portion?

Correct answer: C

Rationale: After administering a narcotic medication, any unused portion should be discarded with another nurse as a witness. This procedure ensures proper disposal of controlled substances and prevents misuse or diversion. Storing it for later use (Choice B) is not appropriate due to safety concerns and legal regulations. Returning it to the pharmacy (Choice D) is also not recommended as the medication is already out of the pharmacy's control. Documenting the amount wasted (Choice A) is important for accurate record-keeping but does not address the immediate need for safe disposal of the unused narcotic medication.

3. A nurse is reviewing a client's health history and identifies a history of pressure injuries. What intervention should the nurse include in the plan of care?

Correct answer: B

Rationale: The correct intervention for a client with pressure injuries is to apply a moisture-retentive dressing. This type of dressing helps create a moist wound environment, which is conducive to healing. Repositioning the client every 4 hours is important to prevent further pressure injuries, but it is not the primary intervention for existing pressure injuries. Applying a heating pad to the site can increase the risk of tissue damage and is contraindicated for pressure injuries. Keeping the client on bedrest can lead to further complications and delayed healing of pressure injuries.

4. A client with an indwelling urinary catheter is being cared for by a nurse. What finding indicates a catheter occlusion?

Correct answer: A

Rationale: Bladder distention is the correct answer as it indicates that the catheter is not draining properly, which is a sign of occlusion. Frequent urination, hematuria, and burning sensation are not indicative of a catheter occlusion. Frequent urination may suggest a bladder that is not fully emptying, hematuria indicates blood in the urine, and a burning sensation can be a sign of a urinary tract infection, none of which directly relate to a catheter occlusion.

5. A healthcare professional is preparing to administer multiple medications to a client with dysphagia. What action should the healthcare professional take?

Correct answer: C

Rationale: Clients with dysphagia have difficulty swallowing, so providing medications through a straw can help control the flow and prevent aspiration. Offering medications with a full glass of water (Choice A) may increase the risk of aspiration. Crushing medications and mixing them together (Choice B) can alter the medication's effectiveness or cause adverse effects. Mixing medications with applesauce (Choice D) may also present a choking hazard for clients with dysphagia.

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