all of the following measures are recommended to prevent pressure ulcers except
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Nursing Elites

ATI RN

ATI Fundamentals Proctored Exam 2024

1. Which of the following measures is not recommended to prevent pressure ulcers?

Correct answer: A

Rationale: Massaging a reddened area can cause further tissue damage by increasing pressure on already compromised skin. The other options, such as using specialized mattresses, adhering to repositioning schedules, and maintaining good skin care, are all recommended strategies to prevent pressure ulcers by reducing pressure and friction on vulnerable areas of the skin.

2. A healthcare provider is performing a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following actions should the healthcare provider take?

Correct answer: B

Rationale: During a gastric lavage procedure for upper gastrointestinal bleeding, inserting a large-bore NG tube is essential to effectively remove gastric contents and blood. This tube allows for efficient irrigation and suction, aiding in the removal of harmful substances from the stomach. Instilling a large volume of solution or using a cold irrigation solution can lead to complications such as fluid overload or hypothermia. Instructing the client to lie on their right side is not directly related to the gastric lavage procedure.

3. Which of the following interventions promotes patient safety?

Correct answer: D

Rationale: All the listed interventions are essential for promoting patient safety. Assessing the patient’s ability to ambulate and transfer helps prevent falls, demonstrating the signal system ensures effective communication in emergencies, and checking the patient's identification band aids in accurate identification and treatment. By combining these interventions, healthcare providers can enhance patient safety and quality of care.

4. For a rectal examination, the patient can be directed to assume which of the following positions?

Correct answer: B

Rationale: The correct position for a rectal examination is the Sims position, where the patient lies on their left side with the upper knee flexed. This position allows for easy access and visualization of the rectal area for examination.

5. During a client's first hospitalization, which of the following actions ensures the safety of the client?

Correct answer: A

Rationale: During a client's first hospitalization, it is essential to keep unnecessary furniture out of the way to prevent obstacles and ensure a safe environment. This action helps reduce the risk of accidents or falls, promoting the client's safety and well-being. Keeping the lights on at all times may not be necessary and can disrupt the client's rest. Keeping side rails up at all times can restrict the client's movement and independence unnecessarily. Keeping all equipment out of view may hinder the healthcare team's ability to monitor and access necessary tools for providing care.

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