a nurse is reviewing the medical record of a client with a hip fracture which finding is a risk factor for pressure injuries
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Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. A healthcare professional is reviewing the medical record of a client with a hip fracture. Which finding is a risk factor for pressure injuries?

Correct answer: C

Rationale: The correct answer is the use of a special mattress. Special mattresses are designed to reduce pressure on bony prominences, thereby helping to prevent pressure injuries. Frequent repositioning (Choice A) is actually a preventive measure for pressure injuries. Poor nutrition (Choice B) can contribute to delayed wound healing but is not a direct risk factor for pressure injuries. Urinary incontinence (Choice D) can increase the risk of skin breakdown but is not a direct risk factor for pressure injuries.

2. A nurse is performing a focused assessment on a client with a history of chronic obstructive pulmonary disease (COPD). What finding should the nurse expect?

Correct answer: B

Rationale: The correct answer is B: Flushed skin. Flushed skin is a common finding in clients with COPD who are experiencing dyspnea. Increased breath sounds (choice A) are not typically associated with COPD; they may indicate conditions like pneumonia. Nasal flaring (choice C) is more commonly seen in respiratory distress in pediatric patients. Decreased respiratory rate (choice D) is not a typical finding in COPD and could indicate respiratory depression.

3. A client with diabetes mellitus is being taught about the importance of foot care by a nurse. Which instruction should the nurse include?

Correct answer: B

Rationale: The correct answer is B: 'Wear shoes at all times.' Clients with diabetes are at a higher risk of foot complications due to poor circulation and nerve damage. Wearing shoes at all times helps protect their feet from injuries. Choice A is incorrect because toenails should be cut straight across to prevent ingrown toenails. Choice C is incorrect as soaking feet in hot water can lead to burns or skin damage, especially for those with diabetes who may have reduced sensation. Choice D is incorrect because applying lotion between the toes can create a moist environment, increasing the risk of fungal infections.

4. A healthcare professional is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. What finding should the healthcare professional expect?

Correct answer: C

Rationale: Flaring of the nostrils is a sign of increased respiratory effort, which is common in clients with COPD experiencing dyspnea. Choices A, B, and D are incorrect. A decreased respiratory rate is not expected in a client with COPD experiencing dyspnea, as they often have an increased respiratory rate. Flushing of the skin is not a typical finding associated with COPD or dyspnea. While a productive cough can be seen in COPD, it is not specifically related to the increased respiratory effort seen with dyspnea.

5. A healthcare professional is teaching a client about the use of a metered-dose inhaler (MDI). Which instruction should the professional include?

Correct answer: B

Rationale: The correct instruction when using a metered-dose inhaler (MDI) is to shake the inhaler vigorously before use. Shaking the inhaler ensures proper mixing of the medication, which is crucial for effective delivery of the medication into the lungs. Inhaling for a specific duration, holding the inhaler at a certain distance from the mouth, or holding the breath after inhalation are not as critical as ensuring proper mixing of the medication by shaking the inhaler.

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