a nurse is teaching a newly licensed nurse about the stages of wound healing the nurse should include in the teaching that collagen is added to the wo
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Nursing Elites

ATI RN

ATI Exit Exam 2024

1. A nurse is teaching a newly licensed nurse about the stages of wound healing. The nurse should include in the teaching that collagen is added to the wound during which of the following stages?

Correct answer: C

Rationale: The correct answer is C: Proliferative phase. During the proliferative phase of wound healing, collagen is added to the wound to promote tissue regeneration. In the hemostasis phase (choice A), the primary goal is to stop bleeding by forming a blood clot. The inflammatory phase (choice B) involves cleaning the wound and preparing it for healing. The maturation phase (choice D) is when the wound undergoes remodeling and gains strength, but collagen addition primarily occurs during the proliferative phase.

2. What is the best method to assess for fluid overload in patients with heart failure?

Correct answer: A

Rationale: The correct answer is A: Monitor daily weight. Daily weight monitoring is the most accurate method to assess fluid overload in patients with heart failure. Changes in weight can indicate fluid retention before visible signs like jugular vein distention or pitting edema appear. Checking for jugular vein distention (choice B) is helpful but may not be as sensitive as daily weight monitoring. Pitting edema (choice C) and fluid retention (choice D) are signs of fluid overload, but daily weight monitoring is a more proactive approach to detect changes early.

3. A client with hypertension is receiving discharge teaching from a nurse on managing blood pressure at home. Which of the following instructions should the nurse include?

Correct answer: C

Rationale: The correct answer is C: 'Use a blood pressure cuff that fits snugly around the arm.' Using a properly fitting cuff is essential for accurate blood pressure measurements. Choice A is incorrect because the timing of medication administration should be individualized and not specified in the question. Choice B is incorrect as checking blood pressure once a week may not provide sufficient monitoring for a client with hypertension. Choice D is incorrect because stopping medication abruptly once blood pressure is normal can lead to rebound hypertension and complications.

4. A client reports that the medication appears different than what they take at home. Which of the following responses should the nurse take?

Correct answer: D

Rationale: Contacting the pharmacist is the most appropriate action to ensure the correct medication is being administered. This response addresses the client's concern directly and prioritizes patient safety. The other options do not directly address the issue of the medication discrepancy. Option A focuses on the healthcare provider's discussion, not the medication itself. Option B assumes that the current medication is correct without verification. Option C addresses the reason for the prescription but does not verify the medication's correctness.

5. Nurses caring for four clients. Which of the following client data should the nurse report to the provider?

Correct answer: D

Rationale: The correct answer is D. The client with chemotherapy and a low neutrophil count is at risk for infection and requires prompt intervention. Reporting this information to the provider is crucial to ensure appropriate monitoring and management to prevent potential complications. Choices A, B, and C do not indicate an immediate risk that requires immediate provider notification. A client reporting pain with pleurisy, a client draining fluid post-surgery, or a client with a heart rate of 98 per minute postoperative are not urgent enough to warrant immediate reporting compared to the client at risk for infection.

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