a nurse is reviewing the health history of an older adult who has a hip fracture what is a risk of developing pressure injuries
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN

1. A healthcare professional is reviewing the health history of an older adult who has a hip fracture. What is a risk factor for developing pressure injuries?

Correct answer: B

Rationale: Urinary incontinence is a risk factor for developing pressure injuries due to prolonged skin exposure to moisture and irritants. Dehydration (choice A) can contribute to skin dryness but is not a direct risk factor for pressure injuries. Poor nutrition (choice C) can affect wound healing but is not specifically linked to pressure injuries. Poor tissue perfusion (choice D) can increase the risk of tissue damage but is not as directly associated with pressure injuries as urinary incontinence.

2. A healthcare professional is preparing to administer 250 mg of an antibiotic IM. Available is 3 g/5 mL. How many mL would the healthcare professional administer per dose?

Correct answer: A

Rationale: To calculate the mL to be administered, convert 250 mg to grams (0.25 g). Then, set up a proportion: (0.25 g / 3 g) x 5 mL = 0.4167 mL, which rounds to 0.4 mL. Therefore, the healthcare professional would administer 0.4 mL per dose. Choice B (0.3 mL) is incorrect because it does not reflect the accurate calculation. Choice C (0.5 mL) is incorrect as it does not consider the correct conversion and calculation. Choice D (0.6 mL) is incorrect as it provides a value higher than the accurate calculation.

3. A nurse is caring for a client prescribed sildenafil for erectile dysfunction. Which of the following should the nurse monitor?

Correct answer: A

Rationale: The correct answer is A: Blood pressure. Sildenafil, a medication for erectile dysfunction, can cause changes in blood pressure. The nurse should monitor for hypotension as a potential side effect. Monitoring heart rate (choice B) is not a priority when administering sildenafil unless there are pre-existing heart conditions. Temperature (choice C) and respiratory rate (choice D) are typically not directly affected by sildenafil administration, making them less relevant for monitoring in this case.

4. A nurse on a pediatric care unit is delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel?

Correct answer: D

Rationale: The correct answer is D because transporting a stable child to x-ray is a task that can be safely delegated to an assistive personnel. This task does not require clinical judgment or specialized skills. Choices A, B, and C involve assessments and interventions that require nursing judgment and should be performed by a qualified nurse. Initiating a dietary consult for a toddler involves assessing the child's nutritional needs and must be done by a nurse. Administering a glycerin suppository to a preschool-age child requires medication administration skills and knowledge of appropriate dosages, which are within the nurse's scope of practice. Evaluating gastric residual following intermittent feeding of an adolescent is a clinical assessment that requires interpretation and decision-making based on the findings, making it a nursing responsibility.

5. A nurse is assessing a client who has anemia. Which of the following findings should the nurse expect?

Correct answer: B

Rationale: The correct answer is B: Conjunctival pallor. In anemia, there is a decrease in hemoglobin levels, leading to paleness of the conjunctiva. This is a common finding in individuals with anemia. Bounding pulse (choice A) is not typically associated with anemia but can be seen in conditions like hyperthyroidism. Elevated blood pressure (choice C) is not a common finding in anemia; instead, blood pressure may be low due to decreased oxygen-carrying capacity. Glossitis (choice D), or a swollen tongue, can be seen in certain types of anemia but is not as specific or common as conjunctival pallor.

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