an incontinent elderly client frequently wets his bed and eventually develop redness and skin excoriation at the perianal area the best nursing goal f
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Nursing Elites

ATI RN

ATI Proctored Nutrition Exam 2019

1. For an incontinent elderly client who frequently wets his bed and develops redness and skin excoriation at the perianal area, what is the best nursing goal?

Correct answer: A

Rationale: The best nursing goal for an incontinent elderly client with skin excoriation is to ensure that the bed linen is always dry. This helps in preventing further skin breakdown and promoting skin integrity. Choice B, to frequently check the bed for wetness and keep it dry, may not address the issue of prevention if the linen is not consistently dry. Choice C, placing a rubber sheet under the client's buttocks, focuses more on protecting the mattress rather than addressing the client's skin condition directly. Choice D, keeping the patient clean and dry, is important but does not specifically address the preventive aspect of maintaining dry bed linen.

2. What is the glomerular filtration rate for patients with stage 5 chronic kidney disease (CKD)?

Correct answer: A

Rationale: In patients with stage 5 chronic kidney disease (CKD), also known as end-stage renal disease, the kidney function is significantly compromised. This severe condition is characterized by a glomerular filtration rate (GFR) of less than 15 mL/min/1.73 m�, as correctly stated in choice A. Choices B, C, and D suggest higher GFR values, which are not indicative of stage 5 CKD. Specifically, a GFR of less than 30 mL/min/1.73 m� indicates stage 4 CKD, less than 90 mL/min/1.73 m� signifies stage 3 CKD, and a typical healthy individual usually has a GFR of around 125 mL/min/1.73 m�, which is far above the GFR for stage 5 CKD.

3. In order to establish a therapeutic relationship with the client, the nurse must first have:

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

4. Which nutrient is most important for maintaining fluid balance in the body?

Correct answer: B

Rationale: Sodium plays a key role in maintaining fluid balance and regulating blood pressure.

5. Which mineral is a principal component of cell membranes?

Correct answer: A

Rationale: Phosphorus is the correct answer. It is a key component of cell membranes, being part of the phospholipid bilayer that provides structure and controls the movement of substances in and out of cells. Magnesium, iron, and iodine do not serve as principal components of cell membranes. Magnesium is involved in various enzymatic reactions, iron is essential for oxygen transport, and iodine plays a role in thyroid hormone synthesis.

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